VAP Prevention Bundle:
Evidence Review for Oral Care and
Subglottic Suction ETTs
Armstrong Institute for Patient Safety and Quality
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
Objectives
• To review the development of a VAP Prevention
Bundle
• To review the evidence to support interventions in
the VAP Prevention Bundle
Development of
‘VAP Prevention Bundle’
• Funded by NIH/NHLBI
– “A Multifaceted Intervention to Reduce VentilatorAssociated Pneumonia in the ICU”
– Delphi process led by RAND researcher
– Implement in statewide cohort of ICUs
• AHRQ funding
– “Comprehensive Unit-based Safety Program (CUSP) for
Ventilator-Associated Pneumonia”
– Pilot test in at least 2 hospitals in 2 states in anticipation of
a national QI VAP Prevention project
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VAP Prevention Guidelines
• CDC Guidelines
• MMWR Recomm Rep. 2004;53:1-36
• American Thoracic Society/ Infectious
Diseases Society of America
• AJRCCM 2005;171(4):388-416.
• Canadian VAP Prevention Guidelines
• J Crit Care 2008;23(1):138-147.
• Society for Healthcare Epid of America
• ICHE 2008;29:S31-S40.
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Development of a New VAP
Prevention Bundle: Delphi Process
• Interdisciplinary committee (n=155)
– Focus on 65 guideline interventions
• Two web based rating cycles
– First cycle, focus on importance
• effectiveness, strength and volume of clinical
evidence, consistency of findings, and relevance
– Second cycle, focus on importance,
measurability and implementation feasibility
• Scale of 1 to 9, where 1 = low, 9 = essential
• > 90% response rates
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Process measures:
Daily evaluation
• Use a semi-recumbent position ( ≥ 30 degrees).
• Make a daily assessment of readiness to wean.
• Use sedation protocol with sedation vacation and
validated sedation scale (i.e. RASS) at least daily.
• Use chlorhexidine when performing oral care.
• Use subglottic suctioning ETTs in patients expected
to be mechanically ventilated for >72 hours
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Structural measures:
Quarterly evaluation
1. Use a closed ETT suctioning system
2. Change close suctioning catheters only as
needed
3. Change ventilator circuits only if damaged or
soiled
4. Change HME every 5-7 days and as clinically
indicated
5. Provide easy access to NIVV equipment and
institute protocols to promote use
6. Periodically remove condensate from circuits,
keeping the circuit closed during the removal,
taking precautions not to allow condensate to
drain toward patient
ETT endotrachael tube; HME heat moist exchanger; NIVV non-invasive ventilation
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Structural measures:
Quarterly evaluation
7. Use early mobility protocol
8. Perform hand hygiene
9. Avoid supine position
10. Use standard precautions while suctioning
respiratory tract secretions
11. Use orotracheal intubation instead of nasotracheal
12. Avoid use of prophylactic systemic antimicrobials
13. Avoid non-essential tracheal suctioning
14. Avoid gastric over-distention
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Chlorhexidine when
performing oral care
Chlorhexidine when performing oral
care: VAP Prevention Guidelines
• No recommendation can be made for the routine use
of an oral chlorhexidine rinse. (Unresolved issue)
• CDC; MMWR Recomm Rep. 2004;53:1-36
• Recommends regular oral care. CHG effective in
specific populations (ie: CABG); routine use is not
recommended until more data is available.
• ATS/IDSA; AJRCCM 2005;171(4):388-416.
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Chlorhexidine when performing oral
care: VAP Prevention Guidelines
• Oral antiseptic CHG should be considered. Based on 1
level 1 and 2 level 2 trials, use of oral antiseptic CHG may
decrease VAP. Safety, feasibility, and cost considerations
are all very favorable.
• Canadian VAP Prevention Guidelines; J Crit Care
2008;23(1):138-147.
• Perform regular oral care with an antiseptic solution. While
the use of CHG is not specifically addressed, the 3 studies
cited by the guideline all focused on cardiovascular surgery
and demonstrated the efficacy of CHG.
• SHEA; ICHE 2008;29:S31-S40.
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CHG Oral Care: Evidence
• Gingival and dental plaque rapidly becomes
colonized with bacteria in intubated patients
due to poor oral hygiene and lack of
mechanical elimination
• Meticulous oral care reduces microbial
burden in upper airway
• Safety and feasibility of CHG oral care are
DeRiso A. Chest. 1996;109:1556.
favorable
Chan E. BMJ. 2007;10:1136.
Chlebicki M Crit Care Med 2007;35:595.
Topical CHG: 2007 Systematic Review
and Meta-Analysis
• 7 RCTs evaluating CHG (1650 patients)
• Overall 26-30% VAP reduction
– Fixed effects RR 0.74, 95%CI 0.56-0.96
– Random effects RR 0.70, 95%CI 0.47-1.04
• Cardiac Surgery subgroup
– 59% VAP reduction
– RR 0.41, 95% CI 0.17-0.98
Chlebicki MP. Crit Care Med 2007;35:595-602
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Topical CHG: 2007 Systematic Review
and Meta-Analysis
Chlebicki MP. Crit Care Med 2007;35:595-602
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Oral Antiseptics: 2011 Systematic
Review and Meta-Analysis
• 12 RCTs evaluating CHG (2341 patients)
• Overall 38% VAP reduction
– RR 0.72, 95%CI 0.55-0.94
• Results varied by CHG concentration
– 2% > 0.2% > 0.12%
• Cardiac Surgery ICUs 59% VAP reduction
– RR 0.41, 95% CI 0.17-0.98
Labeau Lancet Infect Dis 2011;11:845-54
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Oral Antiseptics: A Systematic
Review and Meta-Analysis
Labeau Lancet Infect Dis 2011;11:845-54
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Oral Antiseptics: A Systematic
Review and Meta-Analysis
• Variation by ICU Type
• Cardiac Surgery only (n=2, 914 patients)
– RR 0.41, 95% CI 0.17-0.98
• Mixed ICUs (n=10, 1294 patients)
– RR 0.77, 95% CI 0.58-1.02
• Surgery or Trauma (n=2, 273 patients)
– RR 0.67, 95% CI 0.50-0.88
Labeau Lancet Infect Dis 2011;11:845-54
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CHG Oral Care:
Recommendations
• Chorhexidine 0.12% oral solution (15 ml bid until
24 hours after extubation) for all intubated
patients
• Exceptions
• Hypersensitivity to component of solution
• <18 years of age
• Brush patients’ teeth bid with soft toothbrush to
remove dental plaque prior to using CHG
• Continue routine q4 hr routine oral care: cleaning
and moistening mouth using oral swabs or sterile
water and gauze
Subglottic suctioning ETTs in
patients mechanically
ventilated for >72 hours
Subglottic suctioning ETTs: VAP
Prevention Guidelines
• Recommend ETTs with a dorsal lumen above the
cuff to allow drainage (by continuous or frequent
intermittent suctioning) of tracheal secretions.
• CDC; MMWR Recomm Rep. 2004;53:1-36
• Recommend specially designed endotracheal tube
(dorsal lumen) for continuous aspiration of subglottic
secretions
• ATS/IDSA; AJRCCM 2005;171(4):388-416.
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Armstrong Institute for Patient Safety and Quality
Subglottic suctioning ETTs: VAP
Prevention Guidelines
• Recommended subglottic secretion drainage in
patients expected to be mechanically ventilated for
more than 72 hours.
• Canadian VAP Prevention Guidelines; J Crit
Care 2008;23(1):138-147.
• Recommend the use of cuffed ETT with in line or
subglottic suctioning.
• SHEA; ICHE 2008;29:S31-S40.
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Subglottic suctioning ETTs:
Evidence
• Drainage of subglottic secretions lessens the
risk of aspiration
• Specially designed endotracheal tubes have
been developed to provide continuous or
intermittent subglottic secretion removal
Kollef M. Chest. 1999;116:1339.
Smulders K. Chest 2002;121:858.
Subglottic Suctioning ETTs
Valles J, et al. Ann Intern Med. 1995;122:179.
Subglottic Suctioning ETTs:
Evidence
• 13 RCTs evaluating subglottic secretion
drainage (2442 patients)
• Overall 45% VAP reduction
– RR 0.55 (95% CI 0.46–0.66)
– NNT = 11
• 1.5 day ICU LOS reduction
• 1.1 day duration of MV reduction
Muscedere J. Crit Care Med. 2011;39:1985.
Subglottic Suctioning ETTs: A
Systematic Review and Meta-Analysis
Muscedere J. Crit Care Med. 2011;39:1985.
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Subglottic Suctioning ETTs: A
Systematic Review and Meta-Analysis
• Similar results if limited to studies of high methodologic quality
• Two studies evaluated only cardiac surgery patients (n=1057)
Muscedere J. Crit Care Med. 2011;39:1985.
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Subglottic Suctioning ETTs: A Cost
Effectiveness Analysis
Conclusion:
Regular utilization of CSS-ETs may produce significant
cost savings, irrespective of the increased costs of CSS-ETs.
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Subglottic Suctioning ETTs:
Recommendations
• Continuous subglottic suctioning system
recommended for patients expected to be
mechanically ventilated for >72 hours
• Unanswered questions
– How to identify pts that will require MV > 3
days; most studies used SDD ETTs for all
patients undergoing major surgery
– Should ETTs be changed if patients require
MV > 3 days.
Next Steps
• Discussion and agreement?
• Data Collection
– Process measures
– Opportunity to advance the science
• Timeline
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