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Thursday, May 29, 2014

Ventilator bundle to prevent Ventilator Associated Pneumonia

By the late 1990s it was known that about 15% of patients intubated and placed on a ventilator acquired what was then termed ventilator associated pneumonia (VAP), and that about 30% of those with VAP would ultimately die.  A major effort was then begun to try to reduce these numbers.

Solid data was now available that allowed the Centers for Disease Control and Prevention (CDC) to compile guidelines for combating VAT.  Considering the limited options for treating pneumonia, the main effort was aimed at prevention.

The initial guidelines included many of the following.  These are often referred to as the essential parts of a "Ventilator Bundle."
  1. Mandatory Education:  Everyone involved in the care of the patient should be aware of VAP and how to prevent and treat it.
  2. Mandatory Infection Control:  Everyone taking care of the patient, including visitors, should be aware of the hospitals infection policy.  The best method of spreading infections is by frequent and vigorous hand washing. This may also include wearing masks and gowns when necessary. Sterile technique should be followed when inserting lines or drawing blood.
  3. Routine Oral Hygiene:  Since bacteria from the upper airway may pool over the cuff, it is essential to keep the upper airway clean.  Many guidelines recommend oral suctioning and cleaning at least every two hours. 
  4. Regular Change-out policy:  Closed suction systems and suction canisters and tubing should be changed every 24 hours.  Ventilator circuits should remain closed at all times, and changed at least once a week.  
  5. Maintain Closed circuit:  The ventilator circuit should remain closed at all times.  Special adapters can be added to the circuit to introduce breathing treatment and metered dose inhalers.  Closed suction systems such as a ballard can be introduced between the ETT and the "Y" to prevent the need to break the circuit in order to suction.  Heated circuits prevent condensation inside the circuit and reduce the need to open the circuit for water removal. Changing ventilator circuits weekly instead of daily may also help reduce the introduction of bacteria to the patient. 
  6. Limit normal saline introduction:  The introduction of normal saline into the ETT to assist with the removal of thick secretions should not be routinely performed by nurses, and should only be done by respiratory therapists on an as needed basis. 
  7. Stress ulcer prophylaxis:  Since gastric contents may work their way to the upper airway and into the lungs, efforts must be made to prevent this.  Since all patients on a ventilator are at increased risk for stress fracture, they should all be treated for this. 
  8. Ventilator extubation protocols:  Creation of weaning protocols are shown to speed up time from intubation to extubation. This forces clinicians to start thinking about weaning the moment a patient is intubated. 
  9. Maintain cuff pressure:  Studies show that a cuff pressure of 30 or greater prevents the micro-aspiration of secretions that pool over the cuff.  To read further about this read the post "What tracheal cuff pressure measurement is ideal?" Cuff pressure should be measured and recorded each shift. While the ETT should be rotated each shift, unnecessary maneuvering of the tube should be avoided.  Also, the cuff pressure should never be less than 20 in adults as this significantly increases the risk of aspiration.  Vigorous suctioning should be performed before rotating the cuff and prior to deflating the cuff.  (1, page 8)
  10. Elevate head 30-45 degrees:  This should prevent the aspiration of stomach contents.  This should be required in all ventialtor care policies. 
  11. Prevent early extubation:  ETT should be adequately secured, and the patient adequately sedated or watched in order to prevent inadvertent or purposeful early patient extubation.  Ventilator protocols should help guide clinicians as to the best extubation time.  
  12. Consider tracheotomy:  If a patient should need to be on a ventilator more than a week, the patient should be trached. Trachs also allow for normal physiologic swallow mechanisms which prevent secretions and stomach contents from being inhaled.  They also make it easier to wean patients, make it so less sedation is required, reduced airway resistance, and enhances secretion removal. It allows application of speaking valves to allow patient to speak, even while on ventilator.  Studies show they also improve overall patient morale.  
  13. Avoid heated moisture exchangers (HME):  Do not use HMEs unless absolutely necessary, such as when you need to transfer the patient. Studies have linked them with an increased risk for VAP. 
  14. Limit sedatives:  This topic continues to be controversial and debated.  Some experts recommend limiting the use of sedatives in the early mornings to make sure the patient awake enough for weaning trials.  Ideally, sedatives should be stopped at least four hours prior to doing weaning parameters or weaning attempts.  However, some experts suggest that some sedatives allow patient to be alert enough to follow commands.  
  15. Daily Chest X-Ray:  Since it is very difficult to know when a patient is developing pneumonia, it is important to have a chest x-ray every morning in order to monitor patient's lungs for signs of pneumonia.  
  16. Prophylactic antibiotic therapy:  Some experts recommend automatically starting patients on a broad spectrum antibiotic to prevent the development of infection.  This is also recommended as the top line treatment for VAP.  
  17. Obtain sputum ASAP after intubation:  Obtaining a sputum sample immediately after intubation will help determine if the patient already has pneumonia, or confirm that the patient did not have pneumonia.  This will help determine if a pneumonia is pre-existing or caused by the ventilator. 
  18. Cleaning equipment: Equipment must be efficiently cleaned between patients in order to prevent contamination from one patient to the next. 
  19. Lower tidal volumes:  These may reduce the inflammatory response seen by higher tidal volumes.  
  20. Serial Lab tests:  Daily laboratory testing can help determine if white blood cell counts are increasing, or other markers, which will show that a patient has an infection. 
This post will be updated as new wisdom is obtained.  The following graphic from the CDC pretty much sums it up.
  1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002,, Kimberly Clark Co., accessed 4/21/14
  2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control,, accessed 4/21/14
  3. "Intubation And VAP: A Complex Condition Requires Bundled Solution,",, accessed 4/23/14

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