Vol. 14 •Issue 10 • Page 73
Improving VAP Outcomes With Airway Clearance
Ventilator-associated pneumonia has been recognized at health care institutions as one of the most serious and costly hospital-acquired infections. In addition to the risk to patient safety, studies show VAP is associated with lengthening intensive care unit stays by up to 22 days and hospital stays by up to 25 days. This can mean an increased hospital cost of more than $40,000 per patient.
Some clinicians are focusing on airway clearance to help combat pneumonia in the ICU. Setting milestones for airway clearance efficacy by using the most reliable medical equipment available can significantly increase the standard of patient care and decrease the incidence of pneumonia.
One hospital leading the fight against VAP is Deborah Heart & Lung Center (DHLC), Browns Mills, N.J. There, clinicians are focusing their resources on combating the incidence of VAP. DHLC focuses on VAP prevention, rather than the traditional reactionary treatment of patients who have already acquired the illness.
Research literature shows the chance of acquiring VAP is high among patients with chronic obstructive pulmonary disease, diabetes or a combination of the two. One-third of DHLC’s patients have these risk factors.
While often necessary, use of a breathing tube and mechanical ventilation makes these patients more prone to infection. However, research shows that using a nontraditional airway clearance device can significantly decrease the number of VAP cases.
Clinicians at DHLC have had success with a specialized endotracheal tube. This tube incorporates a second lumen integrated within the wall of the tube with an opening above the cuff. A suction port connected to the lumen enables evacuation of subglottic secretions with a low-flow continuous suction device.
The endotracheal tube reduces the incidence of VAP by facilitating continuous aspiration of subglottic secretions (CASS). With CASS, bacteria-laden secretions that pool above the endotracheal tube cuff are removed before they can colonize and migrate to the lower airways.
Bacteria in subglottic secretions are thought to be the primary source for development of VAP. Removing these secretions before they can contaminate the lungs reduces the incidence of pneumonia considerably.
REDUCING VAP RATES
The results of a comprehensive study conducted by a specialized task force at DHLC led to our decision to use CASS and the specialized endotracheal tube for all surgery patients requiring intubation, not just those at a higher risk of pneumonia.
DHLC clinicians have found no problems associated with implementation of this practice. In fact, during studies to evaluate the tube/CASS airway clearance method, researchers took diagnostic measures such as minimal leak technique for cuff patency to ensure safety.
The clinicians determined that by preventing potential illnesses at the earliest stage, DHLC’s VAP rate dropped 51 percent over a two-year period.
Additional research and surveillance at DHLC also led to the development of a specialized suction device for CASS. Evaluation of this device showed even further reduction in VAP rates.
Although further studies have found that patients with certain risk factors — such as those over 65 years old — are more likely to develop VAP, this progressive approach means that the same prevention measures are taken on all patients. Being able to avoid an additional system failure for each individual patient is one way health care facilities can maintain the highest standard of health for every patient.
SPREADING THE MESSAGE
DHLC staff is involved in a number of educational initiatives on a regional and national level to share their successful strategies for combating VAP. In cooperation with a Norristown, Pa., medical instrument manufacturer, they developed a multidisciplinary initiative that offers continuing education credit for respiratory therapists and nurses. The program is designed to teach other health care institutions how to reduce the incidence of hospital-acquired pneumonia.
It originated as a symposium attended by outside health care providers who were interested in decreasing the number of cases of VAP at their health care institutions. The topics focus on VAP prevention tactics, increased pre-operative education for the patient, and constant monitoring of potential bacterial contamination. The popularity of the program has led to requests for additional symposiums at various locations across the country.
With a track record over the past five years of decreasing VAP rates by 50 percent to 65 percent, DHLC hopes to spread the message of their success to many other facilities with the same goal.
In an information age when hospital statistics and patient safety standards are easily accessible to the questioning patient, proven track records of reduced VAP episodes can make a difference in the personal decision of where to be treated. Additionally, numerous states now require hospitals to report infection rates, enabling the public to compare statistics and draw their own conclusions about varying levels of patient safety.
Taking a progressive approach such as the tube/CASS airway clearance method to reduce VAP only can help raise the standard of care for patients. A focus on airway clearance will continue to be a key factor for measuring patient safety and determining the level of care at health care institutions across the country.
John James Hill, RRT-NPS, is the technical co-director of respiratory care services at Deborah Heart & Lung Center in Browns Mills, N.J.
Secretion Removal in the ICU
A handful of devices are available to aid secretion removal in ICU patients. Patients should be approached on a case-by-case basis to determine the best modality.
• Assistive cough devices provide a large breath followed by negative pressure to improve mucus clearance in patients with weak diaphragmatic function. Patients with weak coughs or atelectasis may find this device helpful before trying more invasive therapies.
• Intrapulmonary percussive ventilation mobilizes secretions by quickly oscillating air through a mouthpiece. It also can be used to deliver aerosolized medicine. Researchers have found it safe and efficacious for pediatrics and patients with atelectasis.
• Intermittent positive pressure breathing can be used by patients who aren’t intubated. It’s usually used to treat atelectasis and improve lung expansion. Although it’s indicated for patients with impaired airway clearance and to delivery aerosol medications to patients who can’t inhale deeply, only a few studies have validated its efficacy.
• In the pediatric ICU, flexible bronchoscopy is a minimally invasive procedure often used for diagnostics. A recent report showed 75 percent of PICU patients studied showed lung re-expansion in chest X-rays after undergoing flexible bronchoscopy.1
1. Bar-Zohar D, Sivan Y. The yield of flexible fiberoptic bronchoscopy in pediatric intensive care patients. Chest. 2004;125(4):1406-12.