Providers work hard to provide the very best care possible. However, often times, despite the excellent care we provide, our patients die due to other secondary events and disease processes.
Secondary issues such as inflammatory responses, ventilator lung injury (VLI), acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), and ventilator-associated pneumonia (VAP) can lead to death. Why provide excellent care and forget the other issues that often lead to death? Can we lower the incidence of these morbidity/mortality factors? Do we forget about these factors that on the surface seem invisible, but are a huge reason why our patients die? Yes. We treat the acute findings and forget that these issues are just waiting to manifest based on our care. We can do something about it! We can lower the incidence of all these diseases!
VAP is a disease process that has a high incidence of morbidity and mortality.VAP is an infection that patients acquire after being intubated and placed on the ventilator. The incidence of VAP most often occurs within the first 48 hours post-intubation. In the ICU setting, VAP is the leading cause of acquired illness and is associated with longer ICU stays and morbidity and mortality.
There have been multiple studies that have shown significant increases in VAP for patients that were intubated in the emergency department, which constitutes patients intubated in the pre-hospital setting. Deedle, 2013, showed that 20% of the incidence of VAP occurred in the emergency department/pre-hospital setting. In another study, Eckert, 2006, showed that 22% of all trauma patients intubated and placed on the ventilator developed VAP.
Ventilator-associated pneumonia is caused from free colonialized bacteria that are lying dominant in our oropharynx and subglottic region. Because of the acute illness or injury the patient is suffering from, they form large amounts of secretions, blood, or vomit in their subglottic airway. During BVM ventilation, prior to intubation, any secretions and the associated colonized bacteria that are sitting in that subglottic region is then pushed into the lungs. This is the beginning of the VAP cycle of death.
The colonized bacteria cause other associated effects that increase the incidence of VAP. These aerobic pathogens start causing a reduction in salivary flow and this promotes a phenomenon called desiccation. Desiccation is the definition for extreme dryness. This issue decreases the antimicrobials found in saliva. When patients are then intubated, any secretions found in the subglottic region can then manifest into micro aspiration around the endotracheal cuff. In addition, based on our normal lung physiology of breathing via a negative pressure, our patients are now being ventilated via a positive pressure with use of the ventilator. This positive pressure now aids in moving those micro secretions past the ET cuff balloon.
A nursing bundle are specific actions, when done together with other actions, reduce the incidence of VAP. In the hospital setting, the following core treatment options have been shown to drastically decrease the incidence of VAP.
- Elevated the head of bed > 15°
- Oral care
- Subglottic suctioning
- Suctioning prior to intubation
- Oral suctioning of intubated patients
- Titrated sedation
- Daily sedation vacations
- Spontaneous breathing trails
- Early extubation
- Stress ulcer prophylaxis
- DVT prophylaxis
The importance of starting these nursing bundles early will reduce the incidence of VAP. Studies have shown that 42% of patients in the emergency department who stay intubated longer than 48 hours will develop VAP. This increases hospital stays and overall morbidity and mortality. Early interventions lead to better outcomes!
We need to understand that the pre-hospital environment is often the starting point for the formation of VAP. We all have a duty to try to lower the incidence by employing the above care options. We must implement proven strategies in the pre-hospital setting and be a good patient advocate.
One of the biggest issues that can cause high incidences of VAP is the misuse of medication during intubation. Proper procedural RSI techniques need to be initiated to prevent aspiration of secretions. During the RSI procedure, using the proper medications and dosing will allow for a smooth intubation and the reduction of any gagging and associated aspiration of blood, vomit, and secretions seen in the subglottic region.
The biggest mistreatment that causes this issue is attempting intubation with no paralytic after giving your induction agent. Historically, many clinicians have attempted intubation after giving only versed or etomidate. However, studies have shown that overall intubation success rates are significantly higher when providing full RSI medication protocol administration. We need to remember that each medication in the RSI pathway is essential and used for a reason. Skipping a medication can lead to increased difficulties and lower the ability to have first pass success and increase the incidence of aspiration and the potential phenomenon of acquiring VAP.
Proper RSI Medication Protocol:
1. Fentanyl: 1-2 mcg/kg
Used for the sympathetic response associated with the laryngeal stimulation and intubation attempt.
2. Ketamine: 2mg/kg
Excellent sedative/induction agent that is stable in hemodynamically unstable patients and has associated beta-2 brochodilation, and analgesic effects.
3. Etomidate: 0.3 mg/kg
Excellent induction agent. Most popular for initial sedative and induction. Can cause hypotension.
4. Succinylcholine: 2 mg/kg (Max 200mg)
Depolarizing neuromuscular-blocking agent that can increase oxygen consumption. Many relative contraindications. Burns >24hrs, crush injuries >24hrs, malignant hyperthermia potential.
5. Rocuronium: 0.6-1.0 mg/kg
Non-depolarizing neuromuscular-blocking agent. Great paralytic for either initial paralysis or continued paralysis post intubation.
- Dispose of any ETT package opened for > 48 hours
- Label any opened package with a dispose of date @ 48 hours
- Pre-suction any patient prior to intubation regardless of visible secretions.
- Continued use of in-line suctioning via ETT after intubation.
- Use of proper RSI dosing and medication.
- Subglottic and oropharynx suctioning post intubation.
- Double check ETT cuff pressure during ongoing care.
- OG/NG tube placement on all intubated patients
We can all make a difference. We have to understand that the secondary issues that are invisible on the surface often kill our patients. Taking the few extra steps and being mindful of these silent killers will greatly reduce the incidence in VAP and the other associated morbidity factors that cause the mortality seen in our patients.
Borgatta. How to approach and treat VAP in ICU patients. BMC Infectious Diseases 2014;14:211
Garnacho-Montero. How to treat VAP due to MDR pathogens in ICU patients. BMC Infectious Diseases 2014;14:135
Munro. What you call it does matter: new definitions of ARDS and VAP. Am J Crit Care 2012;21(5):305-7
Forel. Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy. Critical Care 2012;16:R65
Dessap. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest 2014;epublished March 20th