Clinical application of a novel gravity-weighted continuous oral suction dental pad in preventing ventilator-associated pneumonia in intubated patients

Ventilator-Associated Pneumonia

Background. Pneumonia is the most common nosocomial infection in intensive care units. Most of ICU-acquired pneumonias occur during mechanical ventilation; about half of them develop in the first four days after intubation. Ventilator-associated pneumonia (VAP) can be a lethal complication as it carries a mortality that may approach 50%. Methods. Continuous subglottic suction was utilized in seventeen post cardiac surgery patients with established VAP as part of the management protocol. These patients were compared with a group of 12 patients who did not have continuous subglottic suction part of their management. Results. Institution of continuous subglottic suction in patients with established ventilator associated pneumonia is of value in reducing the number of ventilator dependent days. It also decreases the likelihood of further deterioration in the pulmonary function and reduces the need for antimicrobial agents. Conclusion. Continuous subglottic suction is beneficial in case of established VAP. It prevents further soilage of the airways, speeds up convalescence and shortens the ICU stay. Ideally, it should be instituted early on in case of prolonged mechanical ventilation as one of the effective measures for the prevention of this kind of pneumonia.

Effectiveness of intrabronchial local anesthesia with a spray catheter and continuous oral suction in reducing cough during bronchoscopy: A prospective study

To establish whether continuous subglottic suctioning (CSS) could be cost-effective. Cost-benefit analysis, based on a hypothetical replacement of conventional ventilation (CV) with CSS. A surgical intensive care unit (SICU) of a tertiary care university hospital in France. All consecutive patients receiving ventilation in the SICU in 2006. Efficacy data for CSS were obtained from the literature and applied to the SICU of our hospital. Costs for CV and CSS were provided by the hospital pharmacy; costs for ventilator-associated pneumonia (VAP) were obtained from the literature. The cost per averted VAP episode was calculated, and a sensitivity analysis was performed on VAP incidence and on the number of tubes required for each patient. At our SICU in 2006, 416 patients received mechanical ventilation for 3,487 ventilation-days, and 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000 ventilation-days). Based on the hypothesis of a 29% reduction in the risk of VAP with CSS than CV, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be €10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. If each patient required 2 tubes during ventilation, the cost would be €1,383.69 per averted VAP episode. Replacement of CV with CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.

Objective. The study focused on the nursing strategies of patients with ventilator-associated pneumonia (VAP) and multicriteria decision analysis (MCDA) in nursing supervision, so as to improve the survival rate and prognosis of patients with VAP. Methods. 200 patients of the database in the ICU who required mechanical ventilation were selected as research subjects. They were divided into control group and intervention group according to different nursing measures. The incidence of VAP was compared between the two groups, and 15 experts were consulted on the prevention measures of VAP. On the basis of ARIMA-GARCH mathematical modeling, using the method of multicriteria decision analysis, the cluster nursing strategy for ventilator-associated pneumonia patients was developed and verified. Results. In the control group, of the 34 patients infected with VAP, Gram-positive bacteria were detected in 11 cases, including 6 cases of Streptococcus pneumoniae, 3 cases of Escherichia coli, and 2 cases of golden yellow Staphylococcus. Gram-negative bacteria were detected in 10 cases, including 5 (50%) cases of Acinetobacter baumannii, 2 cases of Klebsiella pneumoniae, 2 cases of Brucella Bacillus, and 1 case of Pseudomonas aeruginosa. In the intervention group, 18 cases were diagnosed with VAP, including 4 (44.4%) cases of bacterial infection, 3 (44.4%) cases of virus infection, and 2 (22.2%) cases of fungal infection. According to the opinions of the 15 experts, a total of 6 bundled measures were adopted to prevent VAP, including 0.1% chlorhexidine for oral care; strict implementation of hand hygiene; the daily wake-up for spontaneous breath training and extubation assessment; continuous subglottic suction; raising the bed head by 30°–45°; and nasal feeding through the nasal tube without special condition. Conclusion. There are many factors that affect the occurrence of VAP in mechanically ventilated patients in the ICU, and the imperfect measures of bundles of care are the main one. The implementation rates of distinct intervention strategies are different. The implementation rate of 2 measures is lower than 95%, which are the continuous subglottic suction and daily wake-up for spontaneous breath training and extubation assessment.

Objective To summarize the value of early mechanical ventilation plus continuous vacuum suction in treatment of serious pulmonary contusion. Methods Forty-eight cases of severe pulmonary contusion were assigned to mechanical ventilation plus continuous vacuum suction (observation group, n=20) and mechanical ventilation plus discontinuous vacuum suction (control group, n=28) according to the random number table. Modes of mechanical ventilation were synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), and positive and expiratory pressure (PEEP). Changes in blood gas analysis, mechanical ventilation time, and associated complications were compared between groups. Results At ventilation time of 6 and 24 hours, PaO2 in observation group was (100.36±5.90)mmHg and (105.34±7.40)mmHg respectively, with significant differences from (75.36±8.95)mmHg and (76.36±8.35)mmHg in control group (P 0.05). Conclusion Early mechanical ventilation with sustained vacuum suction is effective to keep airway clear, improve oxygenation index, decrease PEEP level, and control the duration of mechanical ventilation, but may not lower the risks of ventilator-associated pneumonia and pulmonary atelectasis. Key words: Lung injury; Ventilators, negative-pressure; Treatment outcome

Continuous Subglottic Suctioning for the Prevention of Ventilator-Associated Pneumonia: Potential Economic Implications

Context Ventilator-associated pneumonia (VAP) is one of the important causes of morbidity and mortality in patients admitted to the intensive care unit (ICU) with ventilatory support. Subglottic secretion and their aspirations are primarily responsible for the occurrence of VAP and the risk of tracheal mucosa injury induced by subglottic suctioning and the risk of VAP inpatient on a ventilator has been raised. Aims Aim of this study is to compare the effect of continuous suctioning of subglottic secretions (CSSSs) versus intermittent suctioning of subglottic secretions (ISSS) on tracheal mucosa damage and incidence of VAP inpatient on a ventilator in both study groups. Settings and Design A prospective randomized study. Methods and Material A total of 140 patients requiring intubation or reintubation in the ICU with an expected ventilation duration > 24 hours were included in two groups: CSSS and ISSS. The effect on tracheal mucosa in front of the suction port was assessed after intubation (T0) and before extubation (T1) by bronchoscopy. VAP was compared in both groups on the basis of clinical suspicion and positive culture of bronchoalveolar lavage. Statistical Analysis Used The SAS statistical software version 9.4 (SAS Institute, Cary, North Carolina, United States) has been used for analysis. Chi-square of the Fisher's exact test and Student's t-test or the Wilcoxon rank-sum test were used for analysis. Results A total of 127 patients were included and 89 patients (CSSS, n = 44 and ISSS, n = 45) were evaluable on the primary endpoint. The occurrence or worsening of tracheal mucosal damages did not differ between the two groups (CSSS, n = 12 [27.3%] vs. ISSS, n = 8 [17.7%], p = 0.365). Daily average volume of suctioned secretion was higher with ISSS (72 ± 100 vs. 18 ± 25 mL, p < 0.001). Negligible chance to aspirate was higher with CSSS (0.13 ± 0.15 vs. 0.03 ± 0.06 per day, p < 0.001). Conclusion ISSS did not reduce mucosal damage as compared with CSSS. The aspirated volume was higher and the negligible chance to aspirate was lower with ISSS. The incidence of VAP was lower with CSSS.

The ventilator bundle consists of multiple methods to reduce ventilator-associated pneumonia (VAP) rates in Intensive Care Units (ICU). The aim of the study was to evaluate how the continuous automatic pressure control in tapered cuffs of endotracheal/tracheostomy tubes applied along with continuous automatic subglottic secretion suction affect the incidence of VAP. In the prospective cohort (n = 198), the standard VAP bundle was modified by continuous automatic pressure control in taper-shaped cuff of endotracheal/tracheostomy tubes and subglottic secretion suction. VAP incidence, time to VAP onset, invasive mechanical ventilation days/free days, length of ICU stay, ICU mortality, and multidrug-resistant bacteria were assessed and compared to the retrospective cohort (n = 173) with the standard bundle (intermittent cuff pressure of standard cuff, lack of subglottic secretion suction). A smaller incidence of VAP (9.6% vs. 19.1%) and early onset VAP (1.5% vs. 8.1%) was found in the prospective compared to the retrospective cohort (p < 0.01). Patients in the prospective cohort were less likely to develop VAP (RR = 0.50; 95% CI: 0.29 to 0.85) and early-onset VAP (RR = 0.19; 95% CI: 0.05 to 0.64) and had longer time to onset VAP (median 9 vs. 5 days; p = 0.03). There was no significant difference (p > 0.05) between both cohorts in terms of invasive mechanical ventilation days/free days, length of ICU stay, ICU mortality and multidrug-resistant bacteria. Modification of the bundle for prevention of VAP can reduce early-onset VAP and total incidence of VAP and delay the time of VAP occurrence.

Introduction: Understanding the factors associated with the development of ventilator-associated pneumonia (VAP) in critically ill patients in the intensive care unit (ICU) will allow for better prevention and control of VAP. The aim of the study was to evaluate the incidence of VAP, as well as to determine risk factors and protective factors against VAP. Design: Mixed prospective and retrospective cohort study. Methods: The cohort involved 371 critically ill patients who received standard interventions to prevent VAP. Additionally, patients in the prospective cohort were provided with continuous automatic pressure control in tapered cuffs of endotracheal or tracheostomy tubes and continuous automatic subglottic secretion suction. Logistic regression was used to assess factors affecting VAP. Results: 52 (14%) patients developed VAP, and the incidence density of VAP per 1000 ventilator days was 9.7. The median days to onset of VAP was 7 [4; 13]. Early and late onset VAP was 6.2% and 7.8%, respectively. According to multivariable logistic regression analysis, tracheotomy (OR = 1.6; CI 95%: 1.1 to 2.31), multidrug-resistant bacteria isolated in the culture of lower respiratory secretions (OR = 2.73; Cl 95%: 1.83 to 4.07) and ICU length of stay >5 days (OR = 3.32; Cl 95%: 1.53 to 7.19) were positively correlated with VAP, while continuous control of cuff pressure and subglottic secretion suction used together were negatively correlated with VAP (OR = 0.61; Cl 95%: 0.43 to 0.87). Conclusions: Tracheotomy, multidrug-resistant bacteria, and ICU length of stay >5 days were independent risk factors of VAP, whereas continuous control of cuff pressure and subglottic secretion suction used together were protective factors against VAP.

During upper endoscopic procedures, maintenance of oral suction usually requires a nurse to manually hold the suction tube in place, often for a prolonged period of time. In order to provide assistance to the endoscopist with biopsies or hemostasis, the suction tube is often removed, placed under the pillow or falls on the floor, causing patient discomfort due to accumulation of saliva in the oropharynx. To minimize patient distress and allow continuous hands-free suction of saliva, we have developed a modified suction tube attachment method, using the redundancy of the bite block elastic strap. This simple technique allows fixation of the suction tube within the bite block strap, thereby ensuring continuous aspiration of saliva without the need for nurse-held stabilization. The attachment of the suction tube to the bite block is sufficiently mobile to allow repositioning of the apparatus, if required. Any excess tubing can be placed behind the patient's pillow, to avoid traction of the suction tube. Patient comfort and procedural efficiency may be enhanced by using this simple method for suctioning during various diagnstic or theraputic upper endoscopic procedures, including EUS and ERCP.Figure: Attachment of the elastic strap to the bite block.Figure: Suction tube inserted into bite block with overlapping of strap.Figure: Hands-free suction tube secured to bite block.

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with major morbidity and attributable mortality. Strategies to prevent VAP are likely to be successful only if based upon a sound understanding of pathogenesis and epidemiology. The major route for acquiring endemic VAP is oropharyngeal colonization by the endogenous flora or by pathogens acquired exogenously from the intensive care unit environment, especially the hands or apparel of health-care workers, contaminated respiratory equipment, hospital water, or air. The stomach represents a potential site of secondary colonization and reservoir of nosocomial Gram-negative bacilli. Endotracheal-tube biofilm formation may play a contributory role in sustaining tracheal colonization and also have an important role in late-onset VAP caused by resistant organisms. Aspiration of microbe-laden oropharyngeal, gastric, or tracheal secretions around the cuffed endotracheal tube into the normally sterile lower respiratory tract results in most cases of endemic VAP. In contrast, epidemic VAP is most often caused by contamination of respiratory therapy equipment, bronchoscopes, medical aerosols, water (eg, Legionella) or air (eg, Aspergillus or the severe acute respiratory syndrome virus). Strategies to eradicate oropharyngeal and/or intestinal microbial colonization, such as with chlorhexidine oral care, prophylactic aerosolization of antimicrobials, selective aerodigestive mucosal antimicrobial decontamination, or the use of sucralfate rather than H(2) antagonists for stress ulcer prophylaxis, and measures to prevent aspiration, such as semirecumbent positioning or continuous subglottic suctioning, have all been shown to reduce the risk of VAP. Measures to prevent epidemic VAP include rigorous disinfection of respiratory equipment and bronchoscopes, and infection-control measures to prevent contamination of medical aerosols. Hospital water should be Legionella-free, and high-risk patients, especially those with prolonged granulocytopenia or organ transplants, should be cared for in hospital units with high-efficiency-particulate-arrestor (HEPA) filtered air. Routine surveillance of VAP, to track endemic VAPs and facilitate early detection of outbreaks, is mandatory.

Effect of continuous oral suctioning on the development of ventilator-associated pneumonia: A pilot randomized controlled trial

Objective To investigate the clinical effect of the improved continuous subglottic approach in patients with mechanical ventilation. Methods A total of 90 ICU patients with mechanical ventilation, were divided into observation group and control group 1 and control group 2 by random digits table method,each group was 30 cases.The observation group used the improved continuous subglottic suction. The control group 1 used the way of continuous 24 h suction under glottis. The control group 2 used the way of every 2 h suction under glottis combined with subglottic. The incidence of ventilator-associated pneumonia (VAP), the rate of tube blockage, the amount of subglottic secretion and the damage of airway mucosa were observed. Results The incidence of 7 d VAP in the observation group was 3.33%(1/30), which was not significantly different from that in the control group 1 and the control group 2 (P>0.05), but it was lower than the incidence of VAP at home and abroad. The rate of plugging in the observation group was 6.67%(2/30), and that in the control group 1 was 23.33%(7/30), and the difference was statistically significant (χ2=4.320, P<0.05). The daily flow rate of subglottic secretion was (30.93 ± 8.01) ml/d in the observation group, and (19.75 ± 6.52) ml/d in the control group 2, the difference was statistically significant (t=7.542, P<0.05). The injury rate of airway mucosa in the observation group was 10.00% (3/30), and 33.33%(10/30) in the control group 1, the difference was statistically significant (χ2=4.812, P<0.05). Conclusions The improvement suction under glottis method can be widely applied in clinical practice,which can effectively reduce the incidence of VAP, subglottic tube plugging rate, fully drainage of subglottic secretions, the degree of airway mucosa damage, reduce nursing workload compared with intermittent subglottic. Key words: Respiration, artificial; Improvement; Subglottic aspiration

Nosocomial infection is a major cause of morbidity and mortality. In the ICU, ventilator-associated pneumonia (VAP) represents the most prevalent and visible hospital-acquired infection (HAI). Although some evidence-based strategies reduce the incidence of VAP, despite a recent policy drive toward zero VAP rates, no evidence supports feasibility of VAP eradication. Furthermore, in the era of resource constraints, cost-effectiveness of various strategies is critical to consider. Recent approaches to VAP prevention conglomerate single maneuvers into bundles. Although the cost-effectiveness of some VAP-preventive interventions, such as continuous subglottic suctioning and silver-coated endotracheal tube, has been evaluated singly, less is known about the investments needed to implement the recommended bundled approaches in the context of their ability to prevent VAP and such important downstream implications as the use of antibiotics and other hospital resources. A well designed model from Australia examining the cost-effectiveness of a catheter-related blood stream infection bundle can serve as robust scaffolding for building a credible value proposition for the VAP bundles. Cost-effectiveness of VAP prevention bundles is not known. This is a critical piece of information, particularly as it relates to such important downstream outcomes of VAP prevention as the use of antibiotics and hospital length of stay. Understanding the incremental cost-effectiveness of VAP bundles can help prioritize efforts to minimize the associated morbidity.