Bundle Method in Reducing Pneumonia Associated with Mechanical Ventilation in Newborns and Children : Integrative Review

Infections related to health care are a public health problem, given the repercussions of the event to the morbidity and mortality of the population and having health spending. Pneumonia Associated to Mechanical Ventilation has the incidence of 8.1% to 57.1% in neonates and 23% in children. This study is an integrative literature review aimed to check the scientific production concerning the use of bundle guidelines to reduce of PAV in children and newborns in intensive care units and analyze the results of these research. For data collection, the keyword bundle, and the descriptors infant, newborn; Intensive Care Units, Neonatal Pneumonia, Ventilator-Associated and Child(ren) for online search in databases: PUBMED, SCOPUS, LILACS and CINHAL. The initial result of the search was 891 articles and after application of inclusion and exclusion criteria, the sample resulted in nine articles. This study points out that in general VAP prevention measures found in bundles were effective in reducing PAV rates in neonates and pediatric patients. However, there are still differences in the development of some interventions, especially for newborns. It is necessary to develop other studies, including the better level of evidence to address the use of bundle for PAV prevention of these population, considered more vulnerable to incidents related to health care. Bundle Method in Reducing Pneumonia Associated with Mechanical Ventilation in Newborns and Children: Integrative Review REVIEW


Introduction
Infections associated with Healthcare (IRAS) is currently a public health problem, given the repercussions of the event to the morbidity and mortality of the population and the health expenditures [1].This problem is likely to occur in different population groups, which are directly related to intrinsic and welfare risk factors [2].
As an example of this problem, the Pneumonia Associated to Mechanical Ventilation (PAV) shows up as the second most common nosocomial infection in neonatal intensive care units [1], with an incidence of 8.1% to 57.1%.In neonates, it can be associated with the following risk factors: endotracheal reintubation, enteral nutrition, low birth weight and prematurity.In pediatric patients, it can be associated with endotracheal reintubation, use of the immunosuppressant drug and previous use of antibiotics [3][4].The most common microorganisms isolated in PAV in neonatal units are Pseudomonas aeruginosin; Staphylococcus aureus, Klebsiella pneumonia and Escherichia coli [5].
Regarding this problem, it is essential that health services adopt preventive strategies to minimize the risk of PAV in neonates and pediatric patients through protocols and practices based on evidence that promotes the reduction in infection rates.Among the possible interventions, there is the bundle as a tool for patient safety, which has been the subject of research in other studies [6].
The bundle is a set of measures that when implemented together, it can get better results than when implemented individually.Interventions are based on good practices including constant surveillance, health staff training and adoption of strategies to prevent infections.Therefore, it is necessary to have high adherence by professionals to provide satisfactory results in the infection control [5].
Studies show the effectiveness of PAV prevention bundle, recommended by the Disease Control and Prevention Center (CDC] for adult patients.However, these recommendations should be evaluated for pediatric patients and neonates, because they have different characteristics needing appropriateness of interventions to understand their specificities.
Thus, this review highlights the following study guiding question: What guidelines have been used as bundle component aimed at reducing pneumonia associated with mechanical ventilation in children and newborns in intensive care units?
Thus, the study aims to determine the scientific productions for the use of bundle guidelines to reduce pneumonia associated with mechanical ventilation in children and newborns in intensive care units and analyze the results of the research produced.

Methodology
This is an integrative review, based on the synthesis and comparative analysis of the results of previous studies.Its development was followed by five steps: (1) preparation of an integrative review protocol having the subject, research question, strategy for databases, descriptors, crossings, inclusion and exclusion criteria; (2) data collection to include publications that contribute and relevant answers to the research question; (3) extracting the relevant information contained in the studies (4) data analysis and interpretation; (5) presentation of the review [7].
There were the scientific publications indexed in databases collected to study: PUBMED, SCOPUS, LILACS and CINHAL without restriction for the year of publication.Data collection was conducted in March 2016.The following descriptors were used identified in Descriptors of Health Sciences (DECs)/Medical Subject Headings (MESH): Inclusion criteria were: full articles available on databases without restriction languages that addressed the interventions through the bundles guidelines.Publications on literature review format, editorials, letters, opinion articles, duplicate articles, theses, dissertations or that did not cover the subject of research were excluded.The selection of publications started after reading the titles and abstracts.The studies no available in full and duplicate that had incomplete or insufficient data to answer the research question were later removed, according to the flowchart below: (Figure 1)

Results and Discussion
There were 837 articles found initially, and after reading the titles and abstracts and reading in full, there were nine articles.Table 1 is a summary of the studies identified and included in the integrative review according to the guidelines adopted in the bundle method for the prevention of PAV and the main results.It was observed that four articles (44.5%) were investigated in developed countries, and the rest (55.5%) were carried out in developing countries in South America, Africa, and Asia.Regarding the population, there was a slight predominance in the neonatal, five articles (55.5%) compared to the pediatric age group (44.5%).The most developed type of study was the prospective, almost experimental, with (66.7%), followed by two transversal almost experimental studies (22.2%) and a retrospective case-control (11%).The year with most publication was 2013 (33.3%).
The initial objective of all studies was to analyze the implementation of the bundle to prevent PAV and the impact when reducing PAV rates.Concerning the type of bundle methodology, there were at least three interventions and a last nine interven- Source: Data for the nine articles that were included in the integrative review carried out by the authors tions.The results show a PAV reduction varying between 31% and 71% after bundles implementation.Using the Oxford Center for Evidence-based Me-dicine1 as a reference [17], according to the classification of studies by levels of scientific evidence, the results showed eight studies in the level of evidence type 2C (88.8%), since they were studies of the type observing results (outcomes research) and one study (22.2%) was case-control type, therefore classified as 3B level.
Table 2 shows the interventions described as elements of the bundles and the number of times that each strategy was cited in the nine studies.
The practice of hand hygiene by the health professionals was described in most studies [8][9][10][11][12][13]15]. It is the most important and recognized measure for prevention and control of infections related to care.However, consolidate it as a routine practice of health professionals is a daily challenge [18].A study in a NICU showed a reduction by 38% of PAV rate in neonates of very low-weight after the implementation of a strategy of practical improvement of hand hygiene, proposed by the Vermont Oxford Institute [20].
Regarding the continuing education of health professionals, only three studies used this strategy [9,12,13].It is an instrument contributing to the transformation of care practice, although it is one of the main procedures to adopt safe practices in health care.Therefore, adherence to bundles advocated intervention becomes essential, given that many studies have shown a reduction in IRAS rates by educating health professionals [21,22].
About the regular hygiene of the oral cavity, the results of the studies are conflicting.The IHI recommends an additional way to VAP prevention bundle in pediatric patients, with the adequacy of treatments respecting the specificities of each age of the patient [23].For example, the use of chlorhexidine is not recommended for infants below two months.This generates a variety of interventions for oral hygiene in infants.In studies of the review, there was the use of saline 0.9%, sterile distilled water and breast milk [8,10,13].
It is known about the existence of the protective factor of breast milk in reducing infections and their safety using with newborns at high risk.However, there is no evidence available that address specifically its use in oral hygiene.Thus, this statement requires studies with more rigorous design as randomized controlled trials.Corroborating the findings, another study highlighted that the efficacy of oral cleaning with chlorhexidine in children admitted to the ICU is considered a moderate evidence when related to the reduction in the occurrence of PAV.Brushing teeth is considered a weak evidence [24][25][26].
The intervention of the headboard elevation was present in most of the bundles [10][11][12][13][14][15], which is considered a weak evidence [25].According to the CDC´s recommendation, there are differences in the angle of inclination for newborns and pediatric patients [27].The newborns should remain with head between 10° to 30° degrees, unlike pediatric patients with angles between 30° and 45°.The results of this review showed that only one study with newborns followed the recommendation [13], while in a study of pediatric patients the angle used was 20°-30° [14].
Most of the interventions related to the care of the ventilation circuits and system maintenance without water condensation and exchange only in case of visible dirt or malfunction [9][10][11][12][13]15], followed the recommendations of IHI [23].However, there are differences in the level of evidence of these strategies when applied in neonates because the evidence is considered weak.In pediatric patients, only the circuit exchange intervention was considered a moderate evidence [25].
Among the actions related to the endotracheal tube, there are preference for endotracheal intubation, tube placement periodically checking and maintenance cuff overpressure of 20 mm H 2 O for pediatric patients [11][12][13].These interventions are part of the IHI recommendations, except for the periodic checking of the positioning of the endotracheal tube [23].However, the use of endotracheal tubes with cuff does not apply to newborns.
Among the interventions for maintenance of permeable airways, tracheal aspiration aseptically was identified with system closed and hands off use [9,10,13,14,16].The use of the closed suction system has had low evidence in reducing PAV over the other technique of vacuum, with the system off [4,30].The preference for periodic aspiration of the upper airways over the lower airways [8.10, 13.16] was justified by the fact that the accumulation of secretions in the oropharynx favors the colonization of microorganisms and the occurrence of microaspirations.Endotracheal aspiration should be performed judiciously since it favors increased intracranial of the pressure in premature neonates and promotes the occurrence of intracranial hemorrhage [3].
The daily evaluation of the need for invasive mechanical ventilation is a moderate evidence in some studies of the review [9,10,13,25].Regarding the judgment of the need for sedation, it is preferably applied in pediatric patients, as the sedation of the newborn in the NICU is avoided.Previous use of antibiotics to treat other comorbidities is a risk factor for the development of PAV [3].However, it was an intervention identified in only one study.
Regarding the use of H2 -receptor antagonists of histamine drugs and antacids for the prevention of gastric ulcer in newborns and pediatric patients, there is no recommendation for their use in preventing PAV [23,[28][29][30].This intervention was only identified in only a study of this review [14].

Conclusion
The PAV prevention measures found in bundles, generally, were effective in the reduction of PAV rates in neonates and pediatric patients.However, there are still differences in the development of some interventions, especially for newborns.Among them, there is the practice of cleaning the oral cavity with colostrum, maintaining the elevation of the head between 15° to 30° and periodic circuit exchange.
The bundle objective is not to be a comprehensive reference to the therapy in the literature but a few set of interventions based on evidence carried out jointly by professionals from a health institution.The choice of interventions should consider the cost, ease of implementation and its adherence by the professionals in their care practices.
The results of this review showed that the interventions in the bundles can be applied in different situations, from developing to developed countries.However, the number of articles found on the topic in the investigated databases indicates the need to develop other studies, including the better level of evidence to address the use of the bundle in neonates and pediatric to prevent PAV for this population, considered most vulnerable to incidents related to health care.
International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q1 in category Medicine.

Table 1 .
Interventions identified as elements of the bundles and citation frequency Natal, RN, 2016.
Source: Data for the nine articles that were included in the integrative review carried out by the authors.This article is available at: www.intarchmed.comand www.medbrary.com4

Table 2 .
Description of articles identified on research databases on a bundle for preventing pneumonia associated with mechanical ventilation and results summary.Natal, 2016.