Purpose

1. Purpose To decrease the number of Ventilator-Associated Pneumonias (VAP) at the SMBD-JGH

2. PLAN • What it looks like • How it works • Evidence supporting its claims • Opportunities for the JGH • Potential problems • Product Specs • Education/support

4. PLAN • What it looks like • How it works • Evidence supporting its claims • Opportunities for the JGH • Potential problems • Product Specs • Education/support

7. PLAN • What it looks like • How it works • Evidence supporting its claims • Opportunities for the JGH • Potential problems • Product Specs • Education/support

8. The Attributable Morbidity and Mortality of VAP • Absolute Attributable Mortality • 5.8% (-2.4, 14.0) • Relative Risk Increase • 32.3% (-20.6, 85.1) • Attributable LOS • 4.3 days (1.5, 7.0) • Effect varies across subgroups Heyland Am J Resp Crit Care Med 1999;159:1249

9. Pneumonia in the ICU . Rello J, Crit Care Med 2003 31:2544-51

10. Evidence: Valles 1995 • 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.

13. 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).

14. Conclusion: Subglottic secretion drainage appears effective in preventing early-onset VAP among patients expected to require 72 hours of mechanical ventilation.

15. www.ahrq.gov

19. PREVENTION OFHEALTH-CARE-ASSOCIATED BACTERIAL PNEUMONIA IV. Modifying Host Risk For Infection . Precautions for Prevention of Aspiration • Prevention of aspiration associated with endotracheal intubation • 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

20. Am J Respir Crit Care Med Vol 171. pp 388–416, 2005

21. Major Points and Recommendations for Modifiable Risk FactorsIntubation 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 bacterial pathogens around the cuff into the lower respiratory tract (Level II) 6. 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) 7. 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) 8. 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) 9. Maintaining adequate staffing levels in the ICU can reduce length of stay, improve infection control practices, and reduce duration of mechanical ventilation (Level II)

22. 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.

23. Pneumonia Prevention in the ICU Rello J, Crit Care Med 2003 31:2544-51

24. PLAN • What it looks like • How it works • Evidence supporting its claims • Opportunities for the JGH • Potential problems • Product Specs • Education/support

25. OPPORTUNITIES • Decrease the rate of ventilator-associated pneumonia (VAP) • Improve ICU access by reducing hospital-related LOS from VAP • Potential to decrease mortality and costs associated with development of VAP, especially if earlier extubation.

26. OPPORTUNITIESCALCULATION$ 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

27. OPPORTUNITIESCALCULATIONBENEFIT = ICU ACCESSIBILITY • A 30% decrease in VAP at the JGH ICU would = 14 pneumonias prevented • If the attributable ICU LOS/VAP = 4.3 days, 4.3d X 14 prevented VAP = 60 ICU daysprevented, or accessible for other patients • Cost = $6450/60days = $108/ICU day made accessible Equivalent to costs of treating the prevented VAPs !

28. Indications for EVAC in the OR • Oxygen therapy prior to surgery • Chronically (at home) • Acutely • Emergency cardiothoracic or upper abdominal surgery (< 24 hours of admission/incident) • Depressed level of consciousness pre-op (non-med-related) • Cardiovascular surgery • 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

29. PLAN • What it looks like • How it works • Evidence supporting its claims • Opportunities for the JGH • Potential problems • Product Specs • Education/support

30. Potential obstacles • dedicated suction (regulator, tubing changed qdaily) needed • CRHA 3 hospitals: + $15,000-20,000 • 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)

31. PLAN • What it looks like • How it works • Evidence supporting its claims • Opportunities for the JGH • Potential problems • Product Specs • Education/support

33. Product Specs • Maintain • Suction @ < 20-30 torr • Monitor • EVAC lumen patency (air flush) • ETT cuff pressure

34. PLAN • What it looks like • How it works • Evidence supporting its claims • Opportunities for the JGH • Potential problems • Product Specs • Education/support

35. Education, Support • Canadian Collaborative • Experience, protocols etc. • Manufacturer • Video(Silent Aspiration AW04398) • Checklist • In-servicing • Protocols available from 4 other centers