Case Study in VAP

Vol. 16 •Issue 7 • Page 31
Case Study in VAP

Never Underestimate the Power of Simple ET Tube

As respiratory therapy practitioners, it is our responsibility to be diligent when we use our lifesaving equipment and note any changes that our institution makes regarding it. Whether change comes as a result of a cost-saving measure or just a purchasing error, even a minor change can impact our effectiveness.

Sometimes changes made to cut costs are not always better and can cost hospitals money in the long term. A prime example can be found in something as simple as an endotracheal tube.

When I started working as a therapist in a sunny Florida hospital, all the code boxes and the ER in my hospital were stocked with standard high-volume, low-pressure ET tubes. These tubes were designed to minimize tracheal necrosis and were checked with cuff manometers so pressures did not exceed 25cmH2O.

The hospital system used these tubes extensively, except in the OR where anesthesia personnel had a preference for high-pressure, low-volume ET tubes.

After I had worked at the hospital for about two years, I started noticing the code boxes and ER were being stocked with high-pressure, low-volume tubes. I did not really think too much about it at the time.


In our department, we have monthly meetings where our director reports statistics and changes and shares any pertinent information about which the staff should be aware. The meetings provide a setting where staff can air any grievances as well and serve as a sounding board, allowing therapists input into all types of concerns.

At one particular meeting, the director mentioned that the various campuses of our health system had been reporting a substantial increase in the percentage of patients with ventilator acquired pneumonia (VAP). In fact, the problem was getting serious enough that she had recently attended an upper management meeting set up so caregivers could discuss possible causes for the unusual increase in VAP.

I piped up at that point and mentioned my previous observation that our ET stock had all been switched to high-pressure, low-volume cuffs. Was it possible the cuffs might be the culprits behind our significant increase in VAP cases, I asked.

In high-pressure, low volume cuffs, there is less surface area touching the tracheal wall and unknowingly, as good therapists, we would cruise around the ICUs with our trusty cuff manometer, reducing the pressure below 25 cmH2O. Little did we suspect we might be part of the problem be allowing micro-aspiration leaks from pooled secretions in the back of the oropharynx in the process.

To prove my point, I took two 12-cc syringe sleeves mimicking a trachea and inserted one type of tube into each sleeve, inflating each one to occlusion. Right away, you could see which tube was making the most contact with the sleeve wall. Furthermore, I purposely took a cuff manometer and reduced the air pressure in each one to 25 cmH2O.

The high-pressure, low-volume ET tube lost its grip on the sides of the syringe sleeve and slid out while the high-volume, low-pressure model remained intact and held a seal. It wasn’t rocket science, but the visual was enough to convince our director we might be on the right track for solving the problem.

Subsequent information revealed that either through a cost-saving measure or a purchasing error, our supply of ET tubes had been gradually changing to the high-pressure, low volume variety over the past year. Apparently nobody thought that a little change in something as insignificant as an ET tube would be that important.


The accompanying chart clearly shows the increase of VAP in our hospital up to the point we probed the possibility of VAP being linked to the ET tube change. There was another slight increase in VAP cases a little further down the chart, reflective of the high-pressure, low-volume tubes not being entirely removed from the system. In addition, there was some reluctance for changing the ET tubes in the OR.

To help build a strong case for the use of the low-pressure, high-volume tubes rather than the model favored by anesthesia staff, I attended a monthly OR meeting where most of the anesthesiologists in the hospital system get together and discuss issues pertaining to the operations of the department. My department director arranged for the hospital purchasing agent to attend the meeting as well.

Armed with my syringe sleeves and ET tubes, I merely performed the same visual experiment for the anesthesiologists that I had done for my director. After the presentation, the anesthesiologists had a few questions but unanimously decided to change their ET tubes to high-volume, low-pressure ET tubes for all adult patients. An exception was made for pediatric tubes. The purchasing agent made a note of the high-volume, low-pressure endotracheal tubes desired and even wanted the brand name verified to avoid confusion so there would be no mistakes made when the department ordered new supplies of ET tubes in the future.

Needless to say, it was a good feeling to know I had taken part in one decision which improved our patient care by reducing incidents of VAP, potentially saving our hospital system a fortune by not having to provide non-reimbursed care. In the process, we could shorten our patients’ length of stay.

Whether changes are made to save money or due to error, it pays for therapists to be attentive about their equipment.

As a therapist, you might well be the person who can solve a problem and help your institution save money and impact patient care and recovery time. Our mission is to get people well and home to their loved ones quickly.

That’s what respiratory care is all about, isn’t it?

Thomas O’Donoghue is a Florida practitioner.