A Comparative Study to assess the efficacy of CPI Score Vs APACHE Score to predict ventilator associated Pneumonia among patients admitted in ICU at SMVMCH, Puducherry

 

Dr. R. Danasu, Mrs. R. Sridevi, A. Santhanalakshmi

Sri Manakula Vinayagar Nursing College, Kalitheerthalkuppam, Puducherry

*Corresponding Author E-mail: pavithramuthu1992@gmail.com

 

ABSTRACT:

Ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or longer after mechanical ventilation is given by means of an endotracheal tube or tracheostomy. A comparative descriptive design and quantitative research approach was adopted. 46 samples who are all in mechanical ventilator was selected for the study by using purposive sampling technique and the study was done at SMVMCH by using CPI score and APACHE score. The study result reveals that frequency and percentage wise distribution of the level of the risk of ventilator associated pneumonia by using CPIS score revealed that, out of 23 patients 14 (60.9%) of them had Low risk of getting VAP, 6 (26.1%) had Medium risk of getting VAP and 3 (13%) of them had High risk of getting VAP. Frequency and percentage wise distribution of the level of the risk of ventilator associated pneumonia by using APACHE score reveals that, out of 23 patient 13 (56.5%)of them had Low risk of getting VAP, 9 (39.1%) had Medium risk of getting VAP and 1 (4.3%) of them had High risk of getting VAP. Mean and standard deviation values are 5.30, 1.36 in CPI score and In APACHE score their mean and standard deviation values are 25. 21, 6.59. calculated un-paired ‘t’ test value of t = -14.18 shows statistically significant difference between Comparison of the level of the risk of ventilator associated pneumonia among patient on ventilator by using CPI and APACHE score respectively.

 

KEYWORDS: Ventilator Associated Pneumonia (VAP), Clinical Pulmonary Infection Score (CPIS), Acute Physiological and Chronic Health Evaluation Score (APACHE), Intensive Care Unit (ICU) Endo-tracheal Tube (ET).

 

 


 

 

Received on 27.06.2019          Modified on 18.07.2019

Accepted on 08.08.2019     © A&V Publications all right reserved

Int. J. Nur. Edu. and Research. 2019; 7(4):584-589.

DOI: 10.5958/2454-2660.2019.00130.3

 

INTRODUCTION:

“If you woke up breathing, congratulation! you have another chance”

                                                      Andrea Boydston

 

Ventilator-associated pneumonia (VAP) is pneumonia that develops 48hours or longer after mechanical ventilation is given by means of an endotracheal tube or tracheostomy. Ventilator-associated pneumonia (VAP) results from the invasion of the lower respiratory tract and lung parenchyma by microorganisms. Intubation compromises the integrity of the oropharynx, trachea which allows oral and gastric secretions to enter the lower airways. Ventilator-associated pneumonia is a type of lung infection that occurs in people who are on mechanical ventilation breathing machines in hospitals. The common diagnostic evaluation to diagnose ventilator associated pneumonia are new infiltration on chest x-ray with 2 or more factors. These factors include temperatures of >38°C or <36°C, White blood cell count greater than 12,000/mm3 or less than 4,000/mm3, purulent secretions from the airways in the lung, and/or reduction in gas exchange. Respiratory secretion sampling – it has two methods, they are bronchoscopic method and non bronchoscopic (blind) method.

 

There are two golden standard method to identify ventilator associated pneumonia are clinical pulmonary infection score and acute physiological and chronic health evaluation score. The CPIS is used to assist in the clinical diagnosis of ventilator-associated pneumonia (VAP) by predicting which patients will benefit from obtaining pulmonary cultures. Use of the CPIS results in the prevention of unnecessary antibiotic administration. The parameters in CPIS includes Temperature (°C), White blood cell count, Tracheal secretions, Oxygenation PaO₂/FiO₂ mm Hg, Pulmonary radiography, Culture of tracheal aspirate specimen.

 

The Acute Physiology and Chronic Health Evaluation II (APACHE II) score helpful in diagnosis of VAP and is considered as the best scoring system to predict mortality in patients with VAP.APACHE II Scoring System has some parameters like Temperature (Degrees C), Mean Arterial Pressure (mmHg), Heart Rate, Respiratory Rate, A-aPO2(FiO2>50%) or PaO2(FiO2<50%), Arterial pH or HCO3, Serum Na+ (mEq/L), Serum K+ (mEq/L), Serum Creatinine, Hematocrit, WBC Count,  Glasgow Coma Score,  Age (years), Chronic Health Problems: 1) Cirrhosis of the liver confirmed by biopsy 2) New York Heart Association Class IV 3) Severe COPD - Hypercapnia, home O2 use, or pulmonary hypertension 4) On regular dialysis or 5) Immuno compromised.

 

WHO-Eastern Meditarian Regional Office Sh. Afhamiet.al. (2013) conducted an observational prospective study on ventilator-associated pneumonia in a teaching hospital in Tehran and use of the Iranian Nosocomial Infections Surveillance software. Study reveals that the frequency of ventilator-associated pneumonia was 21.6% episodes per 1000 ventilator days. The mortality rate for VAP ranges from 24% to 50%, and can reach as high as 76% in specific settings or when infection is caused by high-risk pathogens.

 

Worldwide statistics (2013) the study result shows that there are 3.3 per 1000 ventilator days in ICUs in the United States, in Argentina 46.3 per 1000 device-days, Lebanon 47%, Saudi Arabia 25.2% or 16.8 per 1000 person-days of ventilation, in Thailand 75.3%, in Brazil 16.79 per 1000 Ventilator days. The occurrence of ventilator-associated pneumonia in Asian countries is much higher, and ranges from 3.5 to 46 infections/1000 mechanical ventilation days.

 

In India Sh. Afhamiet.al., (2013) conduted an observational prospective study on ventilator-associated pneumonia in a teaching hospital in Tehran and use of the Iranian Nosocomial Infections Surveillance software. Study reveals that 18% or 22.94 per 1000 ventilator days were seen.

 

Babasaheb Deshmukhet.al., (2017) conducted a prospective observational study on clinical study of ventilator-associated pneumonia in tertiary care hospital, Kolhapur, Maharashtra, India. The study was conducted from the period of two years May 2014 to April 2016. The study result shows that the incidence of VAP was found to be 78% among ICU patients. Majority (36%) patients had diabetes mellitus, 30% had hypertension before the admission. VAP were more in patients with co-morbid conditions. The microbiological results of Endotracheal Aspirate showed that, majority 36% had pseudomonas, 26% had Acinetobacter, 22% had no growth, 14% staphylococci.

 

STATEMENT OF THE PROBLEM:

“A Comparative study to Assess the Efficacy of CPI score vs APACHE score to predict Ventilator Associated Pneumonia among patients admitted in ICU at SMVMCH, Puducherry”.

 

OBJECTIVES:

1.       To assess the risk of ventilator associated pneumonia among patients on ventilator by using CPI score Vs APACHE score.

2.       To compare the efficacy of CPI score Vs APACHE score in Intensive Care Unit to predict ventilator associated pneumonia at SMVMCH.

3.       To correlate the efficacy of CPI score Vs APACHE score in Intensive Care Unit to predict ventilator associated pneumonia with their selected study variables.

 

HYPOTHESIS:  

H1:     There will be a significant difference between cpi score vsapachi score in intensive care unit to predict ventilator associated pneumonia.

H2:     There will be a significant correlation in the efficacy of cpi score vs apache score in intensive care unit to predict ventilator associated pneumonia with their selected study variables.

 

RESEARCH METHODOLOGY:

A comparative descriptive design and quantitative research approach was adopted. 46 samples who are all in mechanical ventilator was selected for the study by using purposive sampling technique and the study was done at SMVMCH by using CPI score and APACHE score.

 

CRITERIA FOR SAMPLE SELECTION:

 

Inclusion Criteria:

·         Patient who are all in mechanical ventilator after 24 hours of intubation.

·         Both male and female.

·         Patient from the age group of Above 21 years.

 

Exclusion Criteria:

·         Patient who are in CPAP mode.

·         Weaning done within 24 hours of intubation.

·         Referral cases from other institution with ET tube intubation.

·         Patient who underwent CABG.

 

ANALYSIS AND INTERPRETATION OF DATA:

This chapter deals with analysis and interpretation of the information collected from 46 Patients admitted in ICU to assess the efficacy of CPI score Vs APACHE score to predict ventilator associated pneumonia among patient admitted in ICU at SMVMCH, Puducherry.

 

Table 1: Frequency and Percentage wise Distribution of Study Variables among patients admitted in ICU. N = 46

Sl. No

Study Variables

Cpi Group

Apache Group

n

%

n

%

1

Age in years

 

 

 

 

 

·   20-30

1

4.4

2

8.7

·   31-40

2

8.7

2

8.7

·   41-50

3

13

4

17.4

·   Above 50 years

17

73.9

15

65.2

2

Gender

 

·   Male

12

52.2

15

65.2

·   Female

11

47.8

8

34.8

3

Residential status

 

·   Urban

0

0

2

8.7

·   Rural

23

100

21

91.3

4

Family income

 

·   3000-5000

4

17.4

2

8.7

·   5001-10000

9

39.1

12

52.2

·   10001-15000

8

34.8

6

26.1

·   Above 15001

2

8.7

3

13

5

Dietary pattern

 

·   Vegetarian

0

0

0

0

·   Non-vegetarian

0

0

0

0

·   Mixed

23

100

23

100

6

Previous history of any illness

 

 

 

 

 

·   Yes

9

39.1

6

26.1

·   No

14

60.9

17

73.9

7

Type of patient

 

·   Operative patient

2

8.7

5

21.7

·   Non operative

21

91.3

18

78.3

8

Route of intubation

 

·   Oral intubation

22

95.7

21

91.3

·   Nasal intubation

0

0

0

0

·   Tracheostomy

1

4.3

2

8.7

9

History of re-intubation

 

·   Yes

0

0

0

0

·   No

23

100

23

100

10

History of re-intubation in the past

 

·   Yes

0

0

0

0

·   No

23

100

23

100

11

Mode of nutrition

 

·   Nasogastric tube feeding

23

100

23

100

·   Total parenteral nutrition

0

0

0

0

12

Duration of hospital stay

 

·   5 days

17

73.9

18

78.3

·   10 days

6

26.1

5

21.7

·   Above 10 days

0

0

0

0

13

History of getting antibiotics

 

·   Yes

23

100

23

100

·   No

0

0

0

0

14

Type of antibiotic

 

·   Broad spectrum antibiotic

0

0

0

0

·   Narrow spectrum antibiotic

0

0

0

0

·   Extended spectrum antibiotic

23

100

23

100

15

Cuff pressure maintained at 20 mm Hg

 

·   Yes

23

100

23

100

·   No

0

0

0

0

16

Position maintained at 30-45

 

·   Yes

23

100

23

100

·   No

0

0

0

0

17

Maintained oral hygiene every 4 hourly

 

·   Yes

23

100

23

100

·   No

0

0

0

0

18

Hand hygiene done by staff nurse before and after each contact with patient

 

·   Yes

23

100

23

100

·   No

0

0

0

0

19

Duration of ventilator support

 

·   1 day

0

0

0

0

·   2 days

23

100

23

100

·   3 days

0

0

0

0

·   Above 4 days

0

0

0

0

20

History of doing subglottic suction by the staff nurse

 

·   Yes

23

100

23

100

·   No

0

0

0

0

21

Sedation vacation

 

·   Done

18

78.3

19

82.6

·   Not done

5

21.7

4

17.4

22

Use of personal protective equipment

 

·   Yes

23

100

23

100

·   No

0

0

0

0

23

Indication for patient on ventilation

 

·   Coronary artery disease

2

8.7

2

8.7

·   Valvular heart disease 

0

0

0

0

·   Myocardial infarction

4

17.4

4

17.4

·   COPD

1

4.3

2

8.7

·   Bronchitis

0

0

0

0

·   sepsis

3

13

6

26.1

·   chronic kidney disease

1

4.3

1

4.3

·   Pleural effusion

3

13

1

4.3

·   Pulmonary embolism

0

0

0

0

·   Diabetic ketoacidosis

0

0

0

0

·   Hypertension

3

13

0

0

·   Diabetes mellitus

2

8.7

0

0

·   Lung abscess

0

0

0

0

·   Pneumonia

1

4.3

0

0

·   Supraventricular tachycardia

0

0

0

0

·   ARDS

0

0

0

0

·   Shock

0

0

1

4.3

·   Malignancy

1

4.3

0

0

·   Poisoning

0

0

0

0

·   Snake bite

0

0

0

0

·   Neurological disorder

0

0

1

4.3

·   Post-operative cases

2

8.7

5

21.7

·   Cirrhosis of liver.

0

0

0

0

 

Table 2: Frequency and percentage wise distribution of the level of the risk of ventilator associated pneumonia among patient on ventilator by using CPI score& APACHE Score. N = 46

Scoring Interpretation

CPI Score

APACHE Score

n

%

n

%

Low risk of getting VAP (4-5)

14

60.9

13

56.5

Medium risk of getting VAP (6-7)

6

26.1

9

39.1

High risk of getting VAP (above 8)

3

13

1

4.3

 

 

Figure 2: Percentage distribution of the level of the risk of ventilator associated pneumonia among patient on ventilator by using CPI score.

 

 

Figure 3: Percentage distribution of the level of the risk of ventilator associated pneumonia among patient on ventilator by using APACHE score.

 

Table 3: Comparison of the level of the risk of ventilator associated pneumonia among patient on ventilator by using CPI AND APACHE score. N = 46

Comparison

Mean

Standard deviaton

‘t’ VALUE

‘p’ VALUE

CPI Score

5.30

1.36

-14.18

0.005*

Apache Score

25.21

6.59

*-p < 0.05 significant and ** - P < 0.01 & *** -P < 0.001, Highly Significant

 

 

 

 

Table 4: Correlation of the level of the risk of ventilator associated pneumonia among patient on ventilator by using CPI and APACHE score. N = 46

Comparison

Mean

Standard deviaton

‘t’ Value

‘p’ Value

Cpi score

5.30

1.36

0.541

0.001***

Apache score

25.21

6.59

*-p < 0.05 significant and ** - P < 0.01 & *** -P < 0.001, Highly Significant.

 

Table 5: Correlate the efficacy of CPI score in intensive care unit to predict ventilator associated pneumonia with their selected study variables.  N = 23

Sl.

No

Correlation

Mean

Standard Deviaton

‘r’ Value

‘p’ Value

1

Age in years

3.5652

.8348

1.00

.001

2

Gender

1.4783

.5107

.074

.745

3

Residential status

2.000

.0000

-

-

4

Family income

2.347

.8846

.085

.706

5

Dietary pattern

3.000

.0000

-

-

6

Previous history of any illness

1.608

.4990

.019

.934

7

Type of patient

1.913

.2881

.405

.061

8

Route of intubation

1.087

.4170

-.144

.522

9

Route of intubation

2.000

.0000

-

-

10

History of re-intubation in the past

2.000

.0000

-

-

11

Mode of nutrition

1.000

.0000

-

-

12

Duration of hospital stay

1.260

.4489

-.051

.822

13

History of getting antibiotics

1.000

.0000

-

-

14

Type of antibiotic

3.000

.0000

-

-

15

Cuff pressure maintained at 20 mm Hg

1.000

0000

-

-

16

Position maintained at 30-45

1.000

0000

-

-

17

Maintained oral hygiene every 4 hourly

1.000

0000

-

-

18

Hand hygiene done by staff nurse before and after each contact with patient

1.000

0000

-

-

19

Duration of ventilator support

2.000

0000

-

-

20

History of doing subglottic suction by the staff nurse

1.000

0000

-

-

21

Sedation vacation

1.217

.4217

-.129

.568

22

Use of personal protective equipment

1.000

.0000

-

-

23

Indication

6.956

4.616

.303

.171

*-p < 0.001 significant

 


Table 6: Correlate the efficacy of APACHE score in intensive care unit to predict ventilator associated pneumonia with their selected study variables.                   N = 23

Sl. No

Correlation

Mean

Standard Deviaton

‘r’ Value

‘p’ Value

1

Age in years

3.3913

.9880

1.00

.001*

2

Gender

1.347

.4869

.270

.224

3

Residential status

1.913

.2881

-.074

.743

4

Family income

2.434

.8434

.071

.754

5

Dietary pattern

3.000

.0000

-

-

6

Previous history of any illness

1.739

.4489

.018

.935

7

Type of patient

1.826

.3875

.107

.636

8

Route of intubation

1.173

.5762

-.240

.281

9

Route of intubation

2.000

.0000

-

-

10

History of re-intubation in the past

2.000

.0000

-

-

11

Mode of nutrition

1.000

.0000

-

-

12

Duration of hospital stay

1.217

.4217

-.029

.899

13

History of getting antibiotics

1.000

.0000

-

-

14

Type of antibiotic

3.000

.0000

-

-

15

Cuff pressure maintained at 20 mm Hg

1.000

.0000

-

-

16

Position maintained at 30-45

1.000

.0000

-

-

17

Maintained oral hygiene every 4 hourly

1.000

.0000

-

-

18

Hand hygiene done by staff nurse before and after each contact with patient

1.000

.0000

-

-

19

Duration of ventilator support

2.000

.0000

-

-

20

History of doing subglottic suction by the staff nurse

1.000

.0000

-

-

21

Sedation vacation

1.173

.3875

-.034

.417

22

Use of personal protective equipment

1.000

.0000

-

-

23

 

Indication

4.434

3.435

.140

.534

*-p < 0.05 significant

 


DISCUSSION:

The first objective of the study is to assess the risk of ventilator associated pneumonia among patient on ventilator by using CPI score Vs APACHE score.

 

Clinical Pulmonary Infection Score

Table 3 reveals a that, total number of 23 patients were assessed by using CPI Score throughout the period from admission to discharge. Out of 23 mechanical ventilator patients 14 (60.9%) of them had low risk of getting VAP, 6 (26.1%) of them had medium risk of getting VAP and 3 (13%) of them had high risk of getting VAP.

 

Acute Physiological & Chronic Health Evaluation Score

Table 3 reveals that, a total number of 23 patients were assessed by using APACHE Score throughout the period from admission to discharge. Out of 23 mechanical ventilator patients 13 (56.5%) of them had low risk of getting VAP, 9 (39.1%)of them had medium risk of getting VAP and 1 (4.3%) had high risk of getting VAP.

According to the table 1 the investigator found that the Study variable was assessed by using CPI score and APACHE score. Out of 23 patient 17 (73.9%) of them were comes under age group of above 50 years in CPI score. In APACHE score out of 23 patient 15 (65.2%) of them were comes under age group of above 50 years.

 

This finding of the present study is supported by Blot Set. al., (2014) conducted a prospective study on prevalence, risk factors, and mortality for ventilator-associated pneumonia in middle-aged, old, and very old critically ill patients*.This study was conducted in 27 European Intensive care unit. A total of 1735 was selected. out of 1735 patient, The study result shows that ventilator associated pneumonia occurred in 103 middle aged in the age group of 45- 65 years, 104 old age patient in the age group of 65-74 years and 73 very old patients are in the age of above 75 years.

In gender out of 23 patient 12 (52.2%) of them were male in CPI score and in APACHE score out of 23 patient15(65.2%) of them were male.

 

The second objective was to compare the efficacy of CPI score Vs APACHE score in Intensive Care Unit to predict ventilator associated pneumonia at SMVMCH.

Table 3 reveals that their mean, standard deviation value 5.30, 1.36 in CPI score and the mean, standard deviation in the APACHE SCORE was 25.21, 6.59 respectively.

By comparing the CPI score and APACHE score the higher standard deviation is seen in APACHE score hence APACHE score significant than the CPI score. Reliability of tool was done for CPI score and APACHE score by cronbach’s alpha test. The reliability score for CPI score was 0.45 and for the APACHE score the reliability score is 0.96. After the reliability test the researcher identified that APACHE score is more reliable than the CPI score.

 

According to researcher view the CPI score has lesser number of components and also it has components like tracheal secretion and chest infiltrate, where it delays in time for the result. But while compared to the APACHE score it has in depth and accurate presentation of each and every components. Hence APACHE score is significant than the CPI score.

 

This finding of the present study is supported by Zhou XYet.al., (2015) had conducted a prospective cohort study on a comparison of APACHE II and CPIS scores for the prediction of 30-day mortality in patients with ventilator-associated pneumonia.The study was conducted in multi speciality hospital, China. Out of 135 patients with VAP, 39 died; the 30-day mortality was 28.9%. APACHE II and CPIS scores were significantly higher in non-survivors compared to survivors. The finding of the study reveals that APACHE II is useful for predicting 30-day mortality in patients with VAP, but the CPIS does not have good discrimination and calibration for predicting mortality.

 

The third objective was to correlate the efficacy of CPI score Vs APACHE score in Intensive Care Unit to predict ventilator associated pneumonia with their selected study variables.

Table 5 shows correlate the efficacy of CPI score in intensive care unit to predict ventilator associated pneumonia with their selected study variables.The efficacy of CPI score in intensive care unit to predict ventilator associated pneumonia the variables like age in years, gender, family income, previous history of any illness, type of patient and indication indicates the positive correlation.

 

Age shows positive correlation because patients in the age group comes under above 50 years of age. As age increases the lung alveoli function is reduced. This the reason why patient in the ventilator are in the age group of above 50 years. Previous history illness indicates that with the presensence of comorbid condition increased the risk of ventilator associated pneumonia.

 

The efficacy of CPI score in intensive care unit to predict ventilator associated pneumonia the variables like route of intubation and sedation vacation indicates the negative correlation and other variables are constant, there is no correlation in the efficacy of CPI score in intensive care unit to predict ventilator associated pneumonia.

 

Table 6 shows correlate the efficacy of APACHE score in intensive care unit to predict ventilator associated pneumonia with their selected study variables. The efficacy of APACHE score in intensive care unit to predict ventilator associated pneumonia the variables like age in years, gender, family income, previous history of any illness and indication indicates the positive correlation.

In the reliability test through cronbach’s alpha test, The researcher identified that APACHE score is more reliable than the CPI score. In APACHE score the 15 members are in the category of above 50 years, when the age increases the alveoli function is reduced and it affect the lung to perform its function effectively. Previous history of illness it increased the risk of getting VAP. Some researches shows that the patient with co-morbid condition are more risk for getting VAP. If the patient indicated with the diagnosis of Chronic Obstructive Pulmonary Disease these indication also increased the risk of getting VAP.

 

The efficacy of CPI score in intensive care unit to predict ventilator associated pneumonia the variables like residential status, route of intubation, duration of hospital stay and sedation vacation indicates the negative correlation and other variables are constant, there is no correlation in the efficacy of APACHE score in intensive care unit to predict ventilator associated pneumonia.

 

CONCLUSION:

This study implies that compare with Clinical pulmonary infection score and acute pulmonary and health evaluation score was effective in predicting the ventilator associated pneumonia among patient in mechanical ventilator.

 

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Received on 30.07.2019          Modified on 21.08.2019

Accepted on 17.09.2019     © A&V Publications all right reserved

Int. J. Nur. Edu. and Research. 2019; 7(4):581-583.

DOI: 10.5958/2454-2660.2019.00129.7