Purpose
To decrease the number of
Ventilator-Associated Pneumonias
(VAP) at the SMBD-JGH
PLAN
1.
2.
3.
4.
5.
6.
7.
What it looks like
How it works
Evidence supporting its claims
Opportunities for the JGH
Potential problems
Product Specs
Education/support
PLAN
1.
What it looks like
2.
How it works
3.
4.
5.
6.
7.
Evidence supporting its claims
Opportunities for the JGH
Potential problems
Product Specs
Education/support
PLAN
2.
What it looks like
How it works
3.
Evidence supporting its claims
1.
4.
5.
6.
7.
Opportunities for the JGH
Potential problems
Product Specs
Education/support
The Attributable Morbidity
and Mortality of VAP
23,7

19
17,9
14
Absolute Attributable
Mortality
5.8% (-2.4, 14.0)

Relative Risk Increase
32.3% (-20.6, 85.1)

%Mortality
ICU LOS
(days)
Cases
Controls
Attributable LOS
4.3 days (1.5, 7.0)

Effect varies across
subgroups
Heyland Am J Resp Crit Care Med 1999;159:1249
Pneumonia in the ICU . Rello J, Crit Care Med 2003 31:2544-51
Evidence: Valles 1995
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Setting: Medical-surgical ICU.
Patients: 190 admitted to ICU during a 33-month period and whose
condition suggested the need for prolonged intubation (>3 days).
Intervention: 76 patients randomly allocated to receive CASS, 77 control
patients allocated to usual care.
Results: CASS vs Controls
–
–
–

19.9 vs 39.6 episodes/1000 ventilator days (relative risk, 1.98; 95% CI, 1.03-3.82)
VAP occurred later in CASS pts 12.0 +/-7.1 days vs 5.9 +/-2.1 days (P = 0.003).
The same microorganisms isolated from protected specimen brush or
bronchoalveolar lavage cultures in patients with VAP were previously isolated from
cultures of subglottic secretions in 85% of cases.
Conclusions: The incidence of nosocomial pneumonia in mechanically
ventilated patients can be significantly reduced by using a simple method that
decreases the chronic microaspirations through the cuff of ETTs.
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5 studies , 896 patients.
Subglottic secretion drainage reduced the incidence of VAP by
nearly half (risk ratio [RR] 0.51; 95% CI 0.37 to 0.71),
primarily by reducing early-onset pneumonia (pneumonia
occurring within 5 to 7 days after intubation).
CASS shortened
– duration of mechanical ventilation by 2 days (95% CI: 1.7-2.3
days)
– ICU length of stay by 3 days (95% CI: 2.1 to 3.9 days)
– delayed the onset of pneumonia by 6.8 days (95% CI: 5.5 to 8.1
days).

Conclusion: Subglottic secretion
drainage appears effective in
preventing early-onset VAP among
patients expected to require 72 hours
of mechanical ventilation.
www.ahrq.gov
PREVENTION OF
HEALTH-CARE-ASSOCIATED
BACTERIAL PNEUMONIA
IV. Modifying Host Risk For Infection
. Precautions for Prevention of Aspiration
1. Prevention of aspiration associated with endotracheal intubation
a.
Use of NIV to reduce the need for and duration of endotracheal
intubation…CATEGORY II
b. …avoid repeat endotracheal intubation…CATEGORY II
c. …orotracheal rather than nasotracheal intubation …CATEGORY IB
d. …use an ETT with a dorsal lumen above endotracheal cuff
to allow drainage (by continuous or frequent intermittent
suctioning) of tracheal secretions that accumulate in the
patient's subglottic area ... CATEGORY II
e. Before …(extubation)…ensure that secretions are cleared from above
the tube cuff. CATEGORY II
Am J Respir Crit Care Med
Vol 171. pp 388–416, 2005
Major Points and
Recommendations for
Modifiable Risk Factors
Intubation and mechanical ventilation.
1. Intubation and reintubation should be avoided, if possible, as it increases the risk of
VAP (Level I)
2. Noninvasive ventilation should be used whenever possible in selected patients with
respiratory failure (Level I)
3. Orotracheal intubation and orogastric tubes are preferred over nasotracheal intubation
and nasogastric tubes to prevent nosocomial sinusitis and to reduce the risk of VAP,
although direct causality has not been proved (Level II)
4. Continuous aspiration of subglottic secretions can reduce the risk
of early-onset VAP, and should be used (Level I)
5. The ETT cuff pressure should be maintained at > 20 cm H2O to prevent leakage of
6.
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8.
9.
bacterial pathogens around the cuff into the lower respiratory tract (Level II)
Contaminated condensate should be carefully emptied from ventilator circuits and
condensate should be prevented from entering either the endotracheal tube or inline
medication nebulizers (Level II)
Passive humidifiers or HMEs decrease ventilator circuit colonization, but have not
consistently reduced the incidence of VAP, and thus they cannot beregarded as a
pneumonia prevention tool (Level I)
Reduced duration of intubation and mechanical ventilation may prevent VAP and can
be achieved by protocols to improve the use of sedation and to accelerate
weaning(Level II)
Maintaining adequate staffing levels in the ICU can reduce length of stay, improve
infection control practices, and reduce duration of mechanical ventilation (Level II)
Ann Intern Med. 2004;141:305-313
Purpose: To develop an evidence-based guideline for VAP prevention
Subglottic Secretion Drainage
On the basis of evidence from five level 2 trials, we
conclude that subglottic secretion drainage is associated
with decreased incidence of VAP, especially early onset
VAP.
Status: We recommend that clinicians consider the use of
subglottic secretion drainage.
Pneumonia Prevention in the ICU
Rello J, Crit Care Med 2003 31:2544-51
PLAN
3.
What it looks like
How it works
Evidence supporting its claims
4.
Opportunities for the JGH
1.
2.
5.
6.
7.
Potential problems
Product Specs
Education/support
OPPORTUNITIES
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Decrease the rate of ventilator-associated
pneumonia (VAP)
Improve ICU access by reducing hospitalrelated LOS from VAP
Potential to decrease mortality and costs
associated with development of VAP,
especially if earlier extubation.
OPPORTUNITIES
CALCULATION
$ COST $
~600 intubations/yr in ICU + ED + Wards (code blue etc)
~600 intubations/yr in OR who would qualify for ventilation > 48 hrs
= 1200 intubations/yr who would qualify for ventilation > 48 hours
Conventional JGH ETT: $1.88/ETT
EVAC : $7.25/ETT
Differential increment in cost
= $5.375/ETT
= 1200 X $5.375 = $6450 /yr
OPPORTUNITIES
CALCULATION
BENEFIT = ICU ACCESSIBILITY

A 30% decrease in VAP at the JGH ICU would =
14 pneumonias prevented
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If the attributable ICU LOS/VAP = 4.3 days,
4.3d X 14 prevented VAP =
60 ICU days prevented, or accessible for other patients
Cost
= $6450/60days = $108/ICU day made accessible
Equivalent to costs of treating the prevented VAPs !
Indications for EVAC in the OR
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Oxygen therapy prior to surgery
Chronically (at home)
Acutely
Emergency cardiothoracic or upper abdominal surgery
(< 24 hours of admission/incident)
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Depressed level of consciousness pre-op (non-med-related)
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Cardiovascular surgery
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–
–
–
–
–
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circulatory arrest contemplated
CV surgery combined with non-cardiac surgery
Intraoperative insertion of Intra Aortic Blood Pump (IABP)
Crash intubation in the Cardiac Catheterization Lab
major aortic reconstruction
+ acute preoperative renal failure
At the discretion of anesthetist when a rocky post-op course is foreseen
PLAN
4.
What it looks like
How it works
Evidence supporting its claims
Opportunities for the JGH
5.
Potential problems
1.
2.
3.
6.
7.
Product Specs
Education/support
Potential obstacles

dedicated suction (regulator, tubing changed
qdaily) needed
– CRHA 3 hospitals: + $15,000-20,000
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Issues re larger outer diameter
(+ 0,8mm)
radiopaque line interrupted by the
Murphy eye reappears at the tip
of the tube. (issue with larger ETT)
PLAN
5.
What it looks like
How it works
Evidence supporting its claims
Opportunities for the JGH
Potential problems
6.
Product Specs
7.
Education/support
1.
2.
3.
4.
Product Specs
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Maintain
– Suction @ < 20-30 torr
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Monitor
– EVAC lumen patency (air flush)
– ETT cuff pressure
PLAN
6.
What it looks like
How it works
Evidence supporting its claims
Opportunities for the JGH
Potential problems
Product Specs
7.
Education/support
1.
2.
3.
4.
5.
Education, Support

Canadian Collaborative
– Experience, protocols etc.

Manufacturer
– Video (Silent Aspiration AW04398)
– Checklist
– In-servicing
– Protocols available from 4 other centers