Respiratory therapists play a crucial role in minimizing intubated patients’ risk of exposure to MDROs and VAP by following proper protocols solutions that help prevent infections.
Each year, multidrug resistant organisms (MDROs)—microorganisms, predominantly bacteria, resistant to one or more classes of antimicrobial agents—kill 23,000 people and infect another two million.1 In addition to their impact on patients, MDROs also wreak havoc on clinical outcomes increasing the length of hospital stays, driving additional admissions to the ICU, more surgical procedures, as well as limiting treatment plans. The economic impact of MDROs is staggering and estimated to be as high as $20 billion in excess direct healthcare costs and $35 billion due to lost productivity.2
MDROs put intubated patients at higher risk of respiratory tract infections as bacteria can colonize around the cuff of the tube, leading to infections and ventilator associated events (VAE), including ventilator associated conditions (VAC), infection-related ventilator-associated complications (IVAC) and possible ventilator-associated pneumonia (PVAP), referred to as ventilator-associated pneumonia (VAP) in this article. VAP extends patients’ duration of mechanical ventilation and increases mortality risk.3 VAP occurs in 9-27% of all patients,4-5 and the risk is highest during the early days of a hospital stay.6-8
Respiratory therapists play a crucial role in minimizing intubated patients’ risk of exposure to MDROs by following proper protocols and solutions that help prevent infections. The following are some best practices for combatting MDROs and VAP.
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1. Noninvasive Ventilation
When possible, the CDC recommends noninvasive positive-pressure ventilation (NIPPV) delivered continuously by face or nose mask and minimizing the duration of ventilation.9 Noninvasive ventilation (NIV) is a popular approach to adult respiratory management in both the emergency department and intensive care unit. It is also used more and more for pediatric patients. Studies have confirmed the benefit of using non-invasive ventilation, mostly in chronic obstructive pulmonary diseases with acute hypercapnic ventilatory failure, in cardiogenic pulmonary edema, and in select populations such as immunocompromised patients. Additionally, some studies have demonstrated a substantial benefit on hospital mortality.10
2. Avoid or Minimize Sedation
Manage ventilated patients without sedatives if possible. For patients who are agitated, it’s preferable to use agents other than benzodiazepines. Practitioners may consider analgesics for patients in pain, antipsychotics, dexmedetomidine, propofol and even reassurance.11 If patients are sedated, they should be awakened once a day. Two randomized controlled trials found that daily sedative interruptions reduced the average duration of mechanical ventilation by 2-4 days.12-13
Patients who are sedated should be assessed for readiness to extubate once a day with spontaneous breathing trials.14-17 Daily spontaneous breathing trials have been associated with extubation 1-2 days earlier.14,18
3. Maintain and Improve Physical Conditioning
Early exercise and mobilization have been found to speed extubation, decrease hospital length of stay and increase the rate of return to independent function.19-27 Financial modeling has even suggested that early mobility/exercise programs could provide cost savings.28
4. Raise the Head of the Bed 30-45 Degrees
Aspiration of gastric contents is a primary route of bacterial entry into the lungs and is an important factor in the development of ventilator-associated pneumonia (VAP).22 One study showed a decrease of 76% in VAP rates when the head of a patient’s bed was raised 30-45 degrees.3 While data is mixed on whether this makes a difference, since this is such a simple approach, it is recommended.
5. Ensure Endotracheal Tubes are Properly Inserted
Improperly inserted ET tubes can lead to tracheal trauma and resulting infection. Therapists should routinely verify appropriate placement of the ET tube. During intubation, direct visualization of the ET tube passing through the vocal cords into the trachea, especially with the use of a video laryngoscope, provides evidence of correct tube placement, but additional techniques such as end-tidal carbon dioxide detector should be used to confirm proper endotracheal tube position.
If capnography is inconclusive, other methods of confirmation such as an esophageal detector device, ultrasonography, or bronchoscopy should be used. Endotracheal tube position should be reconfirmed in all patients when their clinical status deteriorates.29
6. Minimize Secretions above the Endotracheal Tube Cuff
Microaspiration and biofilm formation are most implicated in the development of VAP. Microaspiration occurs when there are microorganisms present in the secretions accumulated above the ET cuff. Biofilm formation is the development of secretions and microorganisms that move along the cuff polymer and inside the lumen, eventually moving to the bronchial tree. Subglottic secretion drainage was designed to evacuate the secretions that gather on top of the cuff.30
A literature review found the use of endotracheal tubes with subglottic drainage reduced VAP rates by 55%, average duration of mechanical ventilation by 1.1 days and intensive care stay by 1.5 days.3 For patients who require more than 48 or 72 hours of intubation, endotracheal tubes with subglottic secretion drainage ports are recommended.3
7. Utilize Saline Rinsing over Air Bolus
Clogged tubes can also increase the risk of VAP. Suction lumens clog up to 44% of the time, preventing effective suctioning of secretions.31 When clogged lumens prevent effective suctioning, subglottic secretions are known to accumulate up to 13mL per hour, increasing the risk of microaspiration.32 As previously mentioned, micro-aspiration of potentially infectious secretions through gaps in the endotracheal tube cuff is known to be a leading cause of VAP.4 Saline rinsing is more effective than air bolus at loosening and clearing clogged suction lumens.12 ET tubes that incorporate subglottic suction valves and integrated rinse ports enables both suctioning and saline rinsing and can help to mitigate the risk of VAP by preventing cross-contamination and microaspiration.
8. Consider a Microthin Polyurethane Cuff
The cuff seal is the final barrier that protects the lungs from aspiration of potentially infectious pharyngeal secretions. When intubated, conventional high volume, low pressure (HVLP) PVC cuffs create channels that permit fluid to leak through the cuff and into the lungs.
Clinicians can consider using ET tubes with advanced microthin polyurethane cuffs to help avoid infection. These tubes are thin and soft, yet strong and “self-seal” for increased protection against fluid leakage. They seal more uniformly against the tracheal wall and may allow fewer secretions to seep around the cuff and into the lungs.3 One example is the Microcuff, which features an advanced micro-thin polyurethane cuff, virtually eliminating the formation of channels typically found in PVC cuffs. The benefit of this cuff is that it provides a superior tracheal seal proven to reduce leakage of potentially infectious secretions into the lungs.33-34
9. Perform Regular Oral Care
Oral hygiene care, including chlorhexidine mouthwash or gel, has been found to reduce the risk of VAP in critically ill patients from 25% to about 19%.35 One study found chlorhexidine decreased the risk of VAP by 36% and suggested treatment with 2% chlorhexidine may be most effective in reducing the incidence of VAP.20
10. Follow Proper Care and Cleaning Guidelines
Bacteria can easily migrate through endotracheal tubes (ET), which can inadvertently help the bacteria harbor and grow in a patient’s lungs. Proper care and cleaning can help minimize the risk of infection. Follow CDC guidelines and manufacturers recommendations regarding sterilization and disinfection of respiratory care equipment—especially ventilator circuits and closed suction systems.
11. Avoid Repeat Endotracheal Intubation
When possible, avoid repeat endotracheal intubation for patients who have received mechanically assisted ventilation.9
12. Adhere to Hospital Infection Prevention Strategies
Clinicians should adhere to hospital-associated infection prevention strategies, including proper hand hygiene, adequate environmental cleaning and antimicrobial stewardship programs. To ensure effective hand hygiene compliance among direct patient care givers, make soap and water/alcohol-based hand gels easily accessible and provide feedback if failure to perform hand hygiene is observed. As part of facilities’ antimicrobial stewardship program, patients with a history of MDRO colonization or infection should be identified at admission to ensure proper precautions are taken.
13. When VAP is Suspected
For patients with suspected VAP, a lower respiratory tract sample should be sent for culture as part of evaluation before administering antibiotic therapy. If there is a high probability of pneumonia, CDC recommends administering prompt therapy, regardless of whether bacteria are found in respiratory tract samples.36
Patients on mechanical ventilation are at high risk of VAP and MDROs, but by following the above strategies, practitioners may improve outcomes for patients. RT
Jerry King, MAEd, RRT, is program director of the University of Alabama at Birmingham School of Health Professions. He has a financial relationship with Avanos Medical Inc. For more information, contact [email protected]
- Antibiotic / Antimicrobial Resistance. Centers for Disease Control and Prevention. 2018.Web. Accessed July 18, 2018. Retrieved from https://www.cdc.gov/drugresistance/index.html.
- Antibiotic Resistance Threats in the United States, 2013. Centers for Disease Control and Prevention. Web. Accessed July 18, 2018. Retrieved from https://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=13
- Klompas, Michael, et al. “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update.” Infection Control and Hospital Epidemiology, vol. 35, no. 8, 2014, pp. 915-936. JSTOR.
- Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867–903.
- Rello J, Ollendorf DA, Oster G, Montserrat V, Bellm L, Redman R, Kollef MH. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122:2121
- Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, Simonneau G, Benito S, Gasparetto A, Lemaire F. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995;333:817–822.
- Antonelli M, Conti G, Rocco M, Bufi M, De Blasi RA, Vivino G, Gasparetto A, Meduri GU. A comparison of noninvasive positive pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998;339:429–435.
- Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi-Benissan G, Dupon M, Reiffers J, Cardinaud JP. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 2001;344:817–822.
- Tablan O, et al. Guidelines for Preventing Health-Care-Associated Pneumonia, 2003. Morbidity and Mortality Weekly Report. March 26, 2004/53(RR03);1-36. Accessed July 18, 2018. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
- Keyt H, Faverio P, Restrepo M. Prevention of ventilator-associated pneumonia in the intensive care unit: A review of the clinically relevant recent advancements. Indian J Med Res. 2014 Jun; 139(6): 814-821. Accessed July 18, 2018. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4164993/.
- Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41(1): 263-306.
- Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 2008;371(9607):126-134.
- Kress, JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342(20):1471-1477.
- Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996;335(25)
- Kollef MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med 1997;25(4):567-574.
- Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest 2000;118(2)459-467.
- Lellouche F, Mancebo J, Jolliet P, et al. A multicenter randomized trial of computer driven protocolized weaning from mechanical ventilation. Am J Respir Crit Care Med 2006;174(8):894-900.
- Esteban A, Frutos F, Robin MJ, et al; Spanish Lung Failure Collaborative Group. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med 1995;332(6):345-350.
- Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373(9678):1874-1882.
- Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin 2007;23(1):81–96. 2007;23(1):81–96.
- Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36(8):2238–2243.
- Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007;35(1):139–145.
- Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci 2011;341(5):373–377.
- Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009;37(9):2499–2505.
- Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010;91(4):536–542.
- Titsworth WL, Hester J, Correia T, et al. The effect of increased mobility on morbidity in the neurointensive care unit. J Neurosurg 2012;116(6):1379–1388.
- Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014;42(5):1024–1036.
- Lord RK, Mayhew CR, Korupolu R, et al. ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med 2013;41(3):717–724.
- Ann Emerg Med.2016;68:152
- Technologic Advances in Endotracheal Tubes for Prevention of Ventilator-Associated Pneumonia. Chest. 2012. Jul; 142(1): 231-238.
- Data on file #R151219. Evaluation of Fluid Leakage Past Tracheal Tube Cuffs: Effects of Tracheal Size
and Cuff Pressure.
- DePew, et. al Subglottic Secretion Drainage: A Literature Review AACN V18N4 2007.
- Dullenkopf KA. Gerber AC, Weiss M. Fluid leakage past tracheal tube cuffs: evaluation of the new Microcuff endotracheal tube. Intensive Care Medicine. 2003; 29:1849-1853.
- CLAIM 00279. Data on file.
- Veitz-Keenan, A and Ferraiolo, D. Oral care with chlorhexidine seems effective for reducing the incidence of ventilator-associated pneumonia. Evidence-Based Dentistry 18, 113-114(2017).
- Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. American Thoracic Society Documents. Am J Respir Crit Care Med. Vol 171. P. 388-416, 2005.