By Mike Fratantoro
Intubation is an important life-saving measure for many acute and chronically ill patients. However, even short-term use can be accompanied by a number of potential complications that prevent patients from recovering in a timely manner. In an effort to learn more about the challenges that clinicians face when treating intubated and ventilated patients, RT Magazine spoke with Nuno Azeredo, associate marketing director at Kimberly-Clark Health Care, who offered his insight on the current state of intubation.
RT: What are the current issues in health care as they relate to patient intubation and ventilation?
There is a strong focus on limiting invasive ventilation due to the complications associated with intubations. At Kimberly-Clark, we’ve focused our research on ventilator associated pneumonia, and we work closely with clinicians to understand their needs for treating ICU patients who are invasively ventilated.
Depending on the prognosis, doctors and clinicians will try a noninvasive ventilation method prior to intubation. However, if a patient has to be intubated, the objective then switches to how quickly the patient can be extubated.
RT: What areas and challenges are clinicians focused on for the day-to-day care of intubated patients?
The major areas of focus that we have heard from clinicians are: Preventing patients from invasive ventilation; managing patients once they are on a ventilator; and minimizing the time they spend on a ventilator.
Right now, we still face challenges in understanding when a patient is ready to be extubated. There are some markers to indicate when a patient is ready, but none of them are a silver bullet. Because of this, clinicians run a series of trials. Many times, the reason why patients fail to wean off of a ventilator is because they are on a ventilator. The therapy itself can force them to be on the ventilator longer due to the breakdown of the airway muscles. As a result, there is a big push by clinicians to maintain the diaphragm and the fitness of the muscle so that the patient is in better physical condition to spontaneously breathe.
Another important focus is making sure the patient is breathing as best as possible. There are secretions that accumulate on the inside of the endotracheal tube. Clearing those secretions and maintaining a clean and clear airway is critical as patients who are ventilated don’t have the ability of clearing secretions that build up in their airways.
For example, think of it as being similar to a pipeline transporting oil: the dirt that accumulates on the walls actually reduces the diameter of the inner pipe. Oil is pushed at a higher pressure to get the same amount through as compared to its normal state. It’s the same thing with an endotracheal tube. Secretions start to build on the walls of the tube, decreasing its circumference and creating a need to clear out the accumulations to reduce the amount of resistance of the air going in and out of the patient, making it easier for the patient to breathe. There are studies that show that by making breathing easier, the patient recovers and can be weaned off the ventilator faster because they are not exercising as much to get a breath in and out.
Another challenge is preventing additional harm in the ICU. If the patient is not infected now, how do we prevent them from becoming infected? When performing a bronchoscopy, not breaking the circuit and keeping the circuit clear are extremely important. Clinicians are also working on ways to diagnose potential infections and ways to adjust antibiotic treatments in order to treat infections quickly.
All of these issues are influencing the patient. Intubation is intended to help patients survive, but at the same time there are potential complications due to ventilation that clinicians need to mitigate to shorten the amount of time patients spend on a ventilator.
RT: In general, what are some of the common intubation treatment methods being used in health care facilities and how are these treatments responding to research and clinical outcomes?
Patients are intubated for many reasons. The type of tube that is used depends on why and the length of time the patient is being intubated. Due to health care costs, especially when a patient is being intubated, often times, they are receiving a standard PVC tube. This is not always the best solution because PVC tubes can overinflate and cause damage in the trachea. Some new technology has addressed this issue. For example, there’s been a push to intubate with tubes made of polyurethane. There are also several manufacturers that are trying different variations on the shape of the cuffs in an effort to minimize trauma to the patient. There are upcoming studies regarding the effects of the cuff shape and a few studies point toward a barrel-shaped polyurethane cuff tube causing less trauma.
For patients who are going to be ventilated over a longer period of time, there has been a move to low-pressure/high-volume cuffs because they prevent microaspirations, which continue to be a big issue. If a patient aspirates bacteria, there will be a higher rate of infections, therefore a clinician will want to seal the airway without creating additional trauma through the pressure of the ETT cuff.
Some institutions and clinicians are moving toward subglottic suctioning. It’s not enough to seal the secretions from seeping down into the lungs—it’s necessary to actively remove them from above the cuff, reducing the chances that they seep beyond the cuff into the lungs. Subglottic suction adds an extra tube that vacuums out the aspirations above the cuff.
Another treatment that is popular in Europe is early tracheostomies. Some studies show that if a clinician knows a patient is going to be on ventilator assistance for a longer period of time, extubating them and inserting a tracheal tube will help them to recover faster. When you have a tracheostomy, the patient can be on it for a longer period of time. The benefit of this is that they tend to use fewer sedatives, so they are more awake and can respond better.
RT: How do you believe the CDC’s new Ventilator-Associated Event (VAE) reporting standards will affect intubation and its product technology?
From the technology perspective, diagnosis is going to be key. There will be more emphasis on early detection of bacteria and infection in order to adjust treatments quicker. Having the ability to get samples of the lungs, and being able to culture and understand what is happening from an infection perspective, will have a tremendous impact.
The new reporting standards will also reinforce the current VAE guidelines, especially as it relates to taking care of the endotracheal tube. For example, making sure that the secretions above the cuff are removed, and making sure that the cuff pressure is constant, because without a set pressure the cuff will allow secretions to flush past the cuff.
RT: Is there any kind of recent or future technology that Kimberly-Clark Health Care is working on that addresses these intubation and ventilation issues that you’ve mentioned so far?
Kimberly-Clark manufactures a polyurethane endotracheal tube that is barrel-shaped, which is the safest cuff material on the market. The KimVent Microcuff Endotracheal Tube provides the best seal at the lowest pressure and causes the least amount of damage to the patient’s trachea while still preventing microaspiration.
In order to better aid clinicians in terms of patient diagnosis, the KimVent BAL-Cath Bronchoscopic Aspirate Sampling Catheter provides clinicians with the ability to quickly extract a sample from the lungs, culture that sample, and make a timely diagnosis so that the patient’s antibiotic therapy can be adjusted as quickly as possible.
The Kimberly-Clark KIMVENT VAP Solutions build on the VAE guidelines. For example, our closed suctioning system allows for the circuit to remain closed, preventing the spread of any type of bacterial infection to other patients or to the caregiver. We also understand that clinicians sometimes need to break the circuit to perform procedures like bronchoscopy. The KimVent Multi-Access Port (MAP) Closed Suction System features a compact rotating manifold with multiaccess ports, allowing clinicians to perform suctioning and other procedures such as bronchoalveolar lavage, bronchoscopy, or MDI drug delivery while maintaining a closed ventilator circuit and without going off of ventilation. RT
Mike Fratantoro is managing editor for RT. For further information, contact [email protected].