Abstract
BackgroundVentilator-associated pneumonia (VAP) surveillance is time consuming, subjective, inaccurate, and inconsistently predicts outcomes. Shifting surveillance from pneumonia in particular to complications in general might circumvent the VAP definition's subjectivity and inaccuracy, facilitate electronic assessment, make interfacility comparisons more meaningful, and encourage broader prevention strategies. We therefore evaluated a novel surveillance paradigm for ventilator-associated complications (VAC) defined by sustained increases in patients' ventilator settings after a period of stable or decreasing support.MethodsWe assessed 600 mechanically ventilated medical and surgical patients from three hospitals. Each hospital contributed 100 randomly selected patients ventilated 2–7 days and 100 patients ventilated >7 days. All patients were independently assessed for VAP and for VAC. We compared incidence-density, duration of mechanical ventilation, intensive care and hospital lengths of stay, hospital mortality, and time required for surveillance for VAP and for VAC. A subset of patients with VAP and VAC were independently reviewed by a physician to determine possible etiology.ResultsOf 597 evaluable patients, 9.3% had VAP (8.8 per 1,000 ventilator days) and 23% had VAC (21.2 per 1,000 ventilator days). Compared to matched controls, both VAP and VAC prolonged days to extubation (5.8, 95% CI 4.2–8.0 and 6.0, 95% CI 5.1–7.1 respectively), days to intensive care discharge (5.7, 95% CI 4.2–7.7 and 5.0, 95% CI 4.1–5.9), and days to hospital discharge (4.7, 95% CI 2.6–7.5 and 3.0, 95% CI 2.1–4.0). VAC was associated with increased mortality (OR 2.0, 95% CI 1.3–3.2) but VAP was not (OR 1.1, 95% CI 0.5–2.4). VAC assessment was faster (mean 1.8 versus 39 minutes per patient). Both VAP and VAC events were predominantly attributable to pneumonia, pulmonary edema, ARDS, and atelectasis.ConclusionsScreening ventilator settings for VAC captures a similar set of complications to traditional VAP surveillance but is faster, more objective, and a superior predictor of outcomes.
Highlights
Screening ventilator settings for ventilator-associated complications (VAC) captures a similar set of complications to traditional Ventilator-associated pneumonia (VAP) surveillance but is faster, more objective, and a superior predictor of outcomes
Ventilated patients are at risk for a wide array of preventable pulmonary complications including pneumonia, barotrauma, fluid overload, pulmonary embolism, pneumothorax, and atelectasis
Each patient was assessed for VAC and for VAP
Summary
Ventilated patients are at risk for a wide array of preventable pulmonary complications including pneumonia, barotrauma, fluid overload, pulmonary embolism, pneumothorax, and atelectasis. Surveillance and public reporting of VAP, is problematic.[1,2] The surveillance definition for VAP requires patients to fulfill radiologic (new and persistent infiltrate, consolidation, or cavitation), systemic (fever, abnormal white blood cell count, or delirium), and pulmonary criteria (any two of change in secretions, worsening oxygenation, rales or bronchial breath sounds, and new onset of cough or dyspnea).[3] Positive cultures of pulmonary secretions are optional Applying this definition is complicated, time consuming, and subject to substantial interobserver variability.[4,5] There is poor correlation between clinical diagnoses of VAP and histologically confirmed infection [6,7,8,9,10] and an inconsistent correlation with patients’ outcomes.[11,12] Many patients diagnosed with VAP are found to have other complications at autopsy.[13] Requiring positive cultures adds little accuracy since endotracheal aspirates, broncholaveolar lavage, and protected specimen brush samples all have relatively poor sensitivity and specificity relative to histology.[14,15,16,17,18] hospitals’ VAP rates can vary markedly depending upon which methodology intensivists select to culture patients’ pulmonary secretions.[19] Hospitals’ rates vary depending upon the prevalence of patients with common conditions that can mimic VAP in the hospitals’ intensive care population.[20,21]. We evaluated a novel surveillance paradigm for ventilator-associated complications (VAC) defined by sustained increases in patients’ ventilator settings after a period of stable or decreasing support
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