Why is the government interested in VAP?

Your question: Why is the government interested in reducing nosocomial pneumonia and VAP?

My answer:  While the powers that be will tell you that the main emphasis of efforts to reduce nosocomial infections such as ventilator associated pneumonia (VAP) are to improve patient outcomes, this is not the complete truth.  Any time you have insurance companies and the government involved in the creation of guidelines to improve outcomes, the ultimate goal, or the bottom line, is saving money.

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Subglottic suctioning

Nearly every study done on the subject shows that the leading cause of ventilator associated pneumonia to be caused by secretions pooling above the endotracheal tube cuff, resulting in gradual, micro-aspiration.

According to studies done as far back as 2002 and reported on by the Centers for Disease Control and Prevention (CDC) suggest that subglottic suctioning may help reduce the risk for micro-aspiration.

A CDC report notes:

The endotracheal tube prevents glottic closure. As a result, the patient is unable to cough and remove secretions in a natural way. However, accumulation or pooling of oropharyngeal secretions above the endotracheal tube cuff occurs and then these fluids can be aspirated. See figure. 

Removal of these secretions by suction can reduce the risk of aspiration and may be the most cost effective and safe intervention. Four studies have shown subglottic suction to be safe and effective,14,38-40while only one study showed no difference in colonization. Figure 2 shows one method of performing subglottic suction with a separate suction catheter placed into the sub-glottic area.

Various ETTs are now available that allow for subglottic suctioning. Studies suggest that ETT that allow for subglottic suctioning help reduce the risk for VAP.
Whether an institution has them depends on budget, and on how the powers that be perceive the results of the various studies.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Intubation And VAP: A Complex Condition Requires Bundled Solution," rtmagazine.com, http://www.rtmagazine.com/2014/04/intubation-vap-complex-condition-bundled-solutions/, accessed 4/23/14

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What is the treatment for VAP?

Question:  What is the treatment of ventilator associated pneumonia (VAP)?

Answer:  Treatment is usually a broad spectrum antibiotic until the specific bug and effective antibiotic is isolated. Other than that, treatment generally includes supportive, and may include oxygen therapy, beta adrenergic therapy, bed rest, etc.  An effort should be made to maintain adequate oxygen saturation.  If a patient cannot maintain an SpO2 of 92% or greater, or 88% or greater if the patient has a chronic lung disease, then BiPAP therapy, or intubation and mechanical ventilation, must be considered as options

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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.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control, http://www.cdc.gov/nhsn/PDFs/slides/VAP-DA_gcm.pdf, accessed 4/21/14
3. "Intubation And VAP: A Complex Condition Requires Bundled Solution," rtmagazine.com, http://www.rtmagazine.com/2014/04/intubation-vap-complex-condition-bundled-solutions/, accessed 4/23/14

Signs and symptoms of ventilator associated pneumonia (VAP)

According to the Centers for Disease Control and Prevention (CDD), the following are generally considered the signs and symptoms of ventilator associated pneumonia (VAP.

• Chest X-ray showing new or progressive diffuse infiltrate which is not attributable to any other cause
• Onset of purulent sputum
• Fever greater than 38.5°C (101°F)
• Leukocytosis
• Positive sputum or blood cultures

Leading causes of nosocomial infectjions

It was around 1972 that studies started to come back showing that patients admitted to hospitals were at an increased risk of infection. It was about this time when the term nosocomial infections started to be used in reference to infections caused by the hospital.

By 2002, studies returned the following results as reported by the Centers for Disease Control and Prevention (CDC)/:

1.  Urinary infections are the most common at 31%, and were linked to indwelling urinary catheters.
2.  Pneumonia is the second most common at 27%, and was linked to intubation and ventilation
3.  Blood stream infections were the third most common at 19%, and were linked to indwelling intravenous catheters

It was these statistics that inspired hospital orientated programs to investigate their causes and methods of their dissolution.

Ventilator associated pneumonia (VAP) statistics

Ventilator associated pneumonia (VAP)  was first recognized around 1972, and by 2002 the Centers for Disease Control and Prevention (CDC) released guidelines designed to prevent VAP.  Since these guidelines were passed the statistics actually look pretty good.

While VAP statistics vary from study to study, the following are some of the results:

1. Pneumonia is the second most common nosocomial infection in the United States at 27% (urinary tract infections is number one at 31%, and blood stream infections is #3 at 19%), according to the CDC
2. Pneumonia is a leading cause of death due to hospital-acquired infections.
3. In 2002, US hospitals reported an estimated 250,000 cases of healthcare-associated pneumonias—36,000 related to deaths, according to the CDC
4. 5-20% of patients wo require mechanical ventilation for greater than 48 hours will develop VAP, and th associated mortality is 15-50%, according to Lorente et al and Porzecanski et al
5. ICU stays in patients with VAP is increased by a mean of 6.1 days, and the excess cost can be as high as $40,000 per patient, according to Restrepo et al and Warren et al. 
6. The VAP death rate is 30%, or between 27% and 43%
7. In 2007, The incidence of VAP in 2007 was 22.8% 
8. In 20007, VAP account for 86% of all cases of nosocomial pneumonia.
9. In 2007, intubated patients had a 3-10 fold greater risk of catching pneumonia
10. The mortality rate attributable to VAP is 27% 
11. The mortality rate is as high as 43% when the causative agent was antibiotic resistant
12. Length of stay in the intensive care unit is increased by 5 to 7 days
13. Hospital length of stay was increased 2- to 3-fold
14. In 2014, the cost is estimated to be an additional $40,000 per hospital admission per patient, and an estimated $1.2 billion per year.
15. By 2012, the number of VAP incidents dropped to 3,957
16. With each day of mechanical ventilation and intubation, the crude VAP rate increases by 1% to 3% and the death risk increases from two-fold to 10-fold
17. The American Thoracic Society reported that ventilator-associated pneumonia occurs in 9% to 27% of all intubated patients.
18. A study published in the American Journal of Respiratory and Critical Care Medicine indicated that an estimated 5.9% of ICU deaths through day 60 could be attributed to VAP.
19. Healthcare costs can increase more than $57,000 per incident of VAP.
20. VAP prevention can reduce both the cost and morbidity associated with mechanical ventilation.

Early statistics, which did not look good, were used as incentives to create guidelines for institutions to institute policies and procedures to reduce these rates. Later statistics show these efforts have worked.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control, http://www.cdc.gov/nhsn/PDFs/slides/VAP-DA_gcm.pdf, accessed 4/21/14
3. "Intubation And VAP: A Complex Condition Requires Bundled Solution," rtmagazine.com, http://www.rtmagazine.com/2014/04/intubation-vap-complex-condition-bundled-solutions/, accessed 4/23/14
4. Bowton, David L, R. Duncan Hite, Shayne Martin, and Robert Sheretz, "The Impace of Hospital-Wide Use of a Tapered-Cuff Endotracheal Tube on the Incidence of Ventilator-Associated-Pneumonia," Respiratory Care, October, 2013, volume 58, number 10, pages 1582-1587

What causes VAP?

Secretions pool above the ETT cuff,
resulting in gradual aspiration.

The first studies linking pneumonia and ventilators started coming out in 1972. While it was first thought pathogens came from the equipment, subsequent studies confirmed that the pathogens came from the patient.  

By 2002, it was known that the pathogens came from either secretions that pooled in the upper airway, or those accumulated in the upper GI tract, and then were aspirated, thereby increasing the risk for developing Ventilator Associated Pneumonia (VAP). 

It was at this time that VAP was also broken down into early onset and late onset (1, page 3):

1. Early Onset: The infection occurs within 48-96 hours of admission, and is generally associated antibiotic sensitive agents, such as:
• Staphylococcus aureus (gram positive)
• Haemophilus influenzae (gram negative)
• Streptococcus pneumoniae (gram positive)
2. Late Onset: The infection occurs 96 hours after intubation, and is generally associated with bacteria that are tough to kill, such as:
• Methicillin Resistant Staphylococcus aureus (MRSA)
• Acinetobacter or Enterobacter 
• Pseudomonas aeruginosa (1, page 3)(2)

In most cases, VAP is associated with more than one causative agent.

The various bacterial agents known to colonize in the lungs of ventilator patients have been known to come from various sources within the body, including: (2)

• Oropharynx (mouth and throat)
• Sinus Cavities (nasal drainage)
• Nares
• Dental Plaque
• Gastrointestinal tract
• Patient to patient (poor hand washing by clinicians)
• Ventilator circuit (2)

It's not necessarily the ventilator itself that raises the risk for pneumonia, but the cuffed endotracheal tube (ETT).  Secretions containing bacteria pool above the cuff, and may be forced into the lower airway during the various activities performed by caregivers, such as:  (2) (1, page 4)(3, page 1583)

• Ventilator induced breaths 
• Instillation of saline into the ETT
• Suctioning
• Coughing
• Repositioning the ETT   (1, page 4)

Complicating this problem is that the ETT prevents normal physiological functions meant to keep the lungs sterile. The resulting factor is an increased risk for developing pneumonia while intubated. (1, page 4)

Other reasons the ETT may cause VAP: (1, page 4)

• It prevents a natural cough
• It prevents humidification of upper airway (causing dry mouth)
• Inhibits upper airway reflexes, such as cough and sneeze
• Inhibits cilliary transport of germs to the upper airway
• Allows germs to bypass the upper airway, allowing them direct access to the lungs
• Act as a reservoir for pathogens by providing a place for biofilm to form
• Having a cuff provides a place for secretions to pool (as noted above) (1, page 4)

There are also certain factors associated with an increased risk: (1, page 4)

• Over age 65
• Underlying chronic illness (COPD, asthma, GERD)
• Immunosuppression (AIDS)
• Depressed consciousness (Sedated, paralyzed)
• Thoracic or abdominal surgery
• Previous antibiotic therapy
• Previous pneumonia or remote infection
• Nasogastric tube placement
• Bolus enteral feeding 
• Gastric over-distension
• Stress ulcer treatment
• Supine patient position (lying flat on back)
• Nasal intubation route
• Instillation of normal saline
• Understaffing 
• Non-conformance to handwashing protocol
• Indiscriminate use of antibiotics
• Lack of training in VAP prevention (1, page 4)

So, you can see here how patients who require intubation and mechanical ventilation are at an increased risk for developing VAP.  Once this information made its way to the mainstream guidelines, protocols, and order sets (Ventilator Bundles) were created in order to attempt to reduce the incidence thereof.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. Augustyn, Beth, "Ventilator Associated Pneumonia: Risk Factors and Prevention,"  Critical Care Nurse, August, 2007, volume 27, number 4, pages 32-29
3. Bowton, David L, R. Duncan Hite, Shayne Martin, and Robert Sheretz, "The Impace of Hospital-Wide Use of a Tapered-Cuff Endotracheal Tube on the Incidence of Ventilator-Associated-Pneumonia," Respiratory Care, October, 2013, volume 58, number 10, pages 1582-1587

The birth of ventilator associated pneumonia (VAP)?

The battle against ventilator acquired pneumonia (VAP) began around 1972.  At this time evidence began to show "the airway of mechanically ventilated patients quickly becomes colonized with gram-negative organisms." (1, page 2)

No one knew about VAP during the 1950s, a time when the wisdom and technology became available to artificially breathe for sick people.  It was first used in operating rooms to breathe for anesthetized patients, although it quickly made it's way to emergency rooms.  It was, of sorts, a revolutionary breakthrough in medicine.  

The initial theory was that the pathogens came from the equipment used, although, as the evidence started to mount, this theory was proven false.  It soon became obvious that the causative agent came from the patient by two primary processes:

1. Bacterial colonization of the upper airway and upper digestive
2. The subsequent aspiration into the lower airway

The medical condition described here soon became known as ventilator acquired pneumonia, also known as VAP.  In order to further study and evaluate it, a definition was needed: 

Pneumonia in patients who have been on mechanical ventilation for greater than 48 hours.

The Centers for Disease Control and Prevention continues to use this definition.  It is assumed that the patient did not have pneumonia at the time of intubation.

Since added to this definition is the following:

Pneumonia that develops within 48 hours of discharge from a location.

So even if the patient has be extubated and is presently among the general population of the hospital, the patient can still be diagnosed with VAP if the patient was on a ventilator continuously at any time during that previous 48 hours. (2, page 10)

Since 1972, much has been learned about VAP and how to treat and, mainly, prevent its occurrence.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control, http://www.cdc.gov/nhsn/PDFs/slides/VAP-DA_gcm.pdf, accessed 4/21/14

Michigan VAP rates on steep decline

I wrote earlier how the Keystone Collaborative in Michigan has been so successful at improving patient outcomes and reducing costs that the Fed is recommending other states come up with a similar program.  New evidence shows that the Keystone Collaborative has helped to significantly lower the rates of ventilator acquired pneumonia (VAP) in Michigan Intensive Care Units.

The new study on at the U.S. Department of Health and Human Services, "Rates of Pneumonia Dramatically Reduced in Patients on Ventilators in Michigan Intensive Care Units," In fact, rates of VAP in Michigan hospitals has declined by 70 percent since the Keystone Collaborative was started.  The study included data from 112 ICUs in Michigan.

This is interesting considering I wrote this post about a presentation I gave about how Keystone Policies helped shoreline significantly reduce the rate of readmission rates for pneumonia patients.

The Keystone Collaborative is significant because it pools resources and wisdom from leaders from hospitals in Michigan and some surrounding states to decide what methodologies are needed to implement best practice medicine to improve outcome and reduce costs.  The Keystone Collaborative then recommends certain core measures for each hospital to try to achieve.

The Core Measures include measures that are proven to work for a specific diagnosis to speed the time from admission to discharge, reduce readmission rates, best practice medicine, and to make sure intensity of service is met in order to make sure the patient meets reimbursement criteria.

I have to note here that I'm not particularly happy that many redundant and unnecessary procedures are the result when hospitals resort to cook book medicine (which is what I think order sets are), in that it basically treats all patients the same.  Yet while this may be a side effect, the overall result for the hospital IS improved outcomes and reduced costs.

This recent study is proof again that that Michigan hospitals like Shoreline are taking steps in the right direction.  This is good for the patients, and it's good for RTs like you and me in that it helps to keep our hospitals financially sound so we can continue to get our paychecks.

The Keystone Committee at Shoreline has created order sets and some protocols that are aimed at accomplishing the core measures designed to implement best practice medicine, evidenced based therapies, prevent complications (like infections due to catheters being inserted too long and ventilators and central lines), and reduce the risk of patient's dying in the ICU.

When it comes to core measures, the study shows an increase from 32 percent to 84 percent in Michigan hospitals that have successfully implemented the core measures.  The study also showed a sharp decline in blood stream infections from central lines and has reduced the number of patients who die in the ICU (see sepsis protocol and extubation protocol).

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Ventilator Bundle

Patients used to be left on ventilators too long. If the attending had the day off, the covering doctor was often leery of extubating. The RT on duty wasn't encouraged to "think wean" because there were no protocols. Procedures performed, and sedation, was essentially left to the covering physician, and often varied from patient to patient.

This policy lead to long ventilator stays, increased chance of getting ventilator acquired pneumonia (VAP), and, thus, increased time in hospital, too many poor outcomes, and all this resulting in increased cost to both the patient (or his insurance, or the government) and the hospital.

Studies were done that showed VAP was very high. In fact, every day on the ventilator increased the risk of VAP by 1 percent. Once a patient has VAP, this increases the days on the vent by 4-6 days on average, which increases hospital stays by 4-9 days.

Likewise, fatality rate for VAP is 20-50%, and ultimately costs the hospital an average of $15,000 to $40,000 per patient. Something needed to be done to improve outcomes. The focus was on reducing VAP, and the emphasis was getting all those who cared for the patient on the same page, and thinking the same things.

And if something was missing, or done wrong, others caring for the patient were encouraged to speak up. Studies (like this one) performed showed the following were the best ways to reduce VAP:

1. Good hand washing
2. Ventilator Weaning or extubation Protocols
3. Decrease Ventilator Circuit Contamination:

• use inline suction catheters
• change inline suction catheter every 7 days
• change vent circuit every 30 days (max)

4. Oral Intubations: Studies (as you can see here at Medscapes.com) show that the risk for acquiring VAP is 75% for nasal intubation as opposed to 29% for orally intubated patients.

5. Patient positioning: Keep HOB 30 degrees or greater to decrease risk of aspiration, and lowers diaphragm to improve ventilation, reducing risk of VAP.

6. ETT cuff pressure 20 or greater (a change from what we learned in RT school)

7. Proper Yankauer care, and replace daily. Contamination can potentially cause VAP.

8. Oral intubation: Studies show the best way to intubate patient s is oral intubation, as orally intubated patients had a 34% chance of developing VAP as opposed to 73% of nasally intubated patients.

9. Swabbing the mouth: Studies show swabbing mouth with chlorhexidine gel 3 times a day reduced the risk of VAP from 66% to 29%.

10. Feedings by gastrostromy or jujunostomy: These have the lowest infection rate according to studies. Long term feedings should be done by these methods. Short term feedings should be done by oral gastric tubes as opposed to nasal gastric tubes.

These have all been proven to greatly reduce the risk of VAP. Poor oral care increases the risk of colonization of the mouth, and this can work it's way to the lungs via secretions. An inflated ETT cuff does not prevent germs from reaching the lungs and cause inflammation and pneumonia.

As you can see from the graph above from the MAYO Clinic, from April through December 2003 there were between 6 and 9 cases of VAP per month. Then, almost by miracle, the number dipped to zero, where it has stayed ever since. So what happened?

In January 2004 the MAYO clinic started what is called the ventilator bundle. This is basically an order form that shows the doctor, nurse and RT what needs to be done to prevent VAP The following are the recommendations for a Ventilator Bundle:

• Elevation of head 30-40 degrees unless medically contraindicated


• Continuous removal of subglottic secretions


• Change ventilator circuit no more often than every 48 hours


• Washing of hands before and after contact with each patient


• Daily Sedation Vacation to assess for weaning daily


• Ventilator Weaning or extubation Protocol (always be thinking wean)


• Prophylaxis for DVT


• Prophylaxis for Peptic Ulcer

Here's a copy of our Ventilator Bundle order form from Shoreline Medical. This is a standard sheet that goes in the doctor's orders section for each patient placed on a ventilator:

• Ventilator Protocol Initiated


• Sedation Protocol Initiated


• Peptic Ulcer Protocol Initiated


• DVT Prophylaxis Protocol Initiated


• Glucose Control Protocol Initiated


• Hold Sedation once per day to assess for weanability per ventilator protocol


• Elevate HOB 30-45 degrees unless contraindicated


• Chest X-Ray daily


• ABG daily


• Sputum C&S ASAP after initiation of vent to rule out colonization at time of vent start


• Bronchodilator therapy if indicated (MDI only)


• Dietitian consult if pt. on vent longer than 24 hours to maintain proper nutrition


• Foley catheter


• Oral care TID to QID and prn


• Suction as indicated, or at least once per shift, preferably with inline suction catheter


• Restraints if approved by physician


• ISOPTO tears 1-2 drops as needed

Since the MAYO Clinic initiated its Ventilator Bundle, they have had one reported case of VAP. Likewise, since we initiated ours, we have had only one case of VAP.

It's kind of nice, because it pretty much puts the RNs, doctors and RTs on the same page, and it makes sure that every thing that can possibly be done to improve outcomes, and speed up time from intubation to extubation is done.

About five years ago Shoreline Medical established what it calls the Keystone Committee designed to establish protocols and policy to improve patient care and reduce costs. This committe consists of a champion physician and members from each department within the hospital, including critical care, respiratory therapy, surgery, emergency, administration, and quality assessment.

Quality improvement, and new research, is duscussed on a monthly bases, and the ventilator is updated accordingly. And Ventilator Bundle Core measures are assessed to make sure all procedures are being completed and charted accordingly.

An example of a core measures analysis for the Bundle can be seen in the picture. The goal is to obtain 90% or better in each area, and this is indicated by the green. Green ultimately means the goal has been met.

The areas marked by red indicate the goal has not been met, and something needs to be done to make sure the measure is improved. Ovarall, based on this data, the problem area is oral care. So the team would look at why we are only at 85%.

Is this because the nurse or RT forgot to chart? Was it because the procedure is ordered every 2 hours and this is not possible when the patient needs to sleep? What can be done to correct the problem?

These are all things we think of at our Keystone meetings, and then the bundle is changed if needed.

For examle, our initial bundle changes our practice of lavage and suctioning, and we not have inline suction catheters to reduce the risk of infections. We also give Ventolin MDIs to vent patients instead of breathing treatments.

For us RTs, we are thinking wean as soon as the patient is intubated. Length of time on vents has greatly diminished as well. If we notice the HOB is not elevated 30 degrees, we move it up. If the patient is not receiving feedings, we notify the nurse. Vice versal when it comes to clean suction equipment, and assuring that a sputum sample is obtained to make sure the patient didn't have pneumonia at the time of admission. We work together.

So, ultimately the goal of the Ventilator Bundle is to:

• Reduce VAP


• Reduce time from intubation to extubation


• Reduce costs


• Improve outcomes

Ventilator Bundles work, and one should be initiated at your hospital too.
This topic was also recently discussed at rtmagazine.com

For studies that show what should be done to reduce VAP check out this post at Critical Care Nurse

Ventilator protocol: Setting up pt. on ventilator; and some information about EtCO2 monitoring

As I've been writing about the past few posts, we have a so-so Ventilator protocol here at Shoreline, and we are currently in the process of updating it.

Just for the record here, the ventilators we use are the Servo 300A and the Servo i.

While the majority of the protocol is actually an extubation protocol, we also have the ability to wean FiO2 to maintain an SpO2 of 92%. Which is nice, because before we used to have to sit on an SpO2 of 100 on a specified FiO2 all night long. Now I can wean it down as low as necessary.

This has got to be better for the patient, considering the hazards of oxygen therapy.

So, basically, when setting up a ventilator, we can pretty much determine the most appropriate respitatory rate, FiO2 and tidal volume for the patient based on the protocol, as opposed to just making up numbers.

Here are the initial vent settings per protocol:

1. FiO2: 40%, and increase to main SpO2 >92% (or as specified by physician).
2. VT: 6-10 ml/kg IBW (for Acute Lung Injury or ARDS use 6 ml/kg IBW)
3. PRVC: 10-14 BPM


4. PEEP: 5


5. ABG within 30 minutes post set-up


6. Automode: per RT discretion


7. Maintain cuff pressure >20


8. Suction and send sputum to lab


9. Perform oral care Q2 hours


10. elevate head of bed 40 degrees

There's a little more than just ventilator settings there, so allow me to explain.

First, our doctor who is championing the protocol has decided that lower tidal volumes are safer for patients than the 10-15cc/kg IBW that is taught in RT school. Actually, people with normal lungs may use 10-15cc/kg IBW, but it's better to be on the safe side with lower tidal volumes.

Likewise, studies have shown lower tidal volumes to be equally effective ventilation.

As per another hospital's ventilator protocol: "Recent literature has shown tidal volumes in the range of 7-10 cc/kg to be effective in ventilation while reducing the risk of barotrauma."

So, the going trend is to start low and increase as indicated, based on ETCO2 (see below) and SpO2 or ABG.

PEEP of 5 is a good place to start, and increase as indicated or as directed by a physician. I discussed PEEP studies a few days ago.

Along with an ABG, an X-Ray should be completed within 30 minutes. Soft wrist restraints as needed, Ativan as needed, NG, etc. are also included in the protocol.

While this is not a ventilator weaning protocol per se, the ability of the RT to turn on automode allows us to basically switch the patient over from PRVC to volume support. In VS, the patient determines his own flow and pressure support.

For the most part, in the aspect, we RTs are allowed to change modes, so long as the mode we choose to change it to is VS. The funny thing is, I think a lot of doctors have little understanding of automode, as even while the patient may have been in Volume Support for three days, some of our doctors continue to order for rate and tidal volume changes thinking that's what the patient will get.

Now this is fine, so long as they understand the changes are in order to maintain a minute ventilation, as opposed to guaranteeing the preset rate and tidal volume.

It can be safe to say that once the patient switches himself to volume support, he has taken the first step in the weaning process.

Basically, the pressure support in volume suport mode can be measured by subtracting static pressure from peak pressure. If PIP is 20 and static is 15, then the pressure support the patient is drawing in is 5, which is actually a good number. Anything under 10 is good. If a patient is sucking in more than 10, then you may be safe to assume the patient is not weanable.

Automode is nice for the patient, because as he wakes up, he is able to actually control the vent, instead of the vent controlling the patient. This was a big selling point for us in choosing to purchase the Servo vents.

When I explain the ventilator to nurses and patients, I tell them that it is "state of the art life support technology, and it actually has a brain that senses when the patient is ready to breath on his own."

And, when the patient stops breathing on his own, the vent will automatically switch back to the PRVC mode. And then back to VS after the patient takes three consecutive spontaneous breaths.

I wouldn't always turn the automode on. If the patient had a cardiac event, or if the patient is not breathing effectively on his own, I would keep the patient in PRVC.

Basically, once the patient is in automode, and stays there, the weaning process is started. The initial vent settings are assuring the patient maintains the desired minute ventilation, but otherwise determining his own settings.

While in school we were taught that the cuff pressure should always be maintained at less than 20 to make sure the circulation to the arteries are not cut off. However, with new research, it has been learned that most patients are intubated for such a short period of time now, that this is less of a concern.

As I've written about before on this blog, the average stay on a ventilator has significanly decreased since the advent of microprosessor ventilators that allow the patient to control the vent instead of the other way around.

So, now we want the cuff pressure to be >20. The reason here is we want to prevent VAP. Also, to prevent Ventilator Acquired Pneumonia (VAP), we make sure that we clean the oral cavity as often as possible. Our protocol recommends Q2 hours. Usually this job is shared between RTs and RNs.

Then, so we can prove later that the patient had pneumonia prior to being placed on the vent, or to prove that we caused it later on, we obtain a sputum as soon as possible and send it to the lab.

Also, we want to make sure the head of bed is elevated to protect the airway, and prevent aspiration, which is another VAP preventative measure.

Ultimately, however, "the guidelines listed above should be considered a starting point for most patients. Adjustments to rate, tidal volume, or inspiratory time should be made according to disease process or as changes in the patient's condition warrants. Closely monitor BP, HR, RR, EtCO2 (as needed), SpO2, and breath sounds for changes in patient status."

Shorter inspiratory times and longer expiratory times may be indicated for some asthma and COPD patients to prevent air trapping.

EtCO2 should be monitored on all ventilator patients. A normal EtCO2 is 40, however the EtCO2 should be coordinated with the ABG so it can be monitored instead of doing ABGs.

There are some conditions that may alter EtCO2 and cause it to read lower than the actual ABG due to shunting. These include:

1. Asthma


2. COPD


3. Severe Pneumonia


4. ARDS


5. Chest trauma


6. pulmonary embolism


7. decreased cardiac output

This is progress based on the latest studies. If you guys think our data is wrong, or if you have new information to add here, please feel free to respond. We RT are continuously trying to stay up to date, or to stay ahead of the curve.

Preventing Ventilator-Associated Pneumonia

How to prevent Ventilator-Associated Pneumonia has been extensively studied. Here are the most common recommendations. Chances are your hospital has already incorporated most of these.

1. Ventilator Bundles are protocols based on best practice medicine. These should be incorporated in all critical care units to assure all of the following guidelines are met. 
2. Good handwashing
3. Sterile technique (as much as possible)
4. Implementing a ventilator extubation protocol to speed up time from intubation to extubation. 
5. Making sure the cuff pressure is always 30 CWP or greater. The idea here is that this will prevent secretions from leaking around the cuff. Higher pressures are acceptable so long as intubation is short term, which is the goal of any intubation.
6. Tracheotomy should be considered for anyone requiring greater than seven days of mechanical ventilation. 
7. Heated wires should be used to limit opening of the circuit (this seems to be no longer an issue)
8. Inline suctioning (such as a Ballard) should be used instead of tracheal lavage and suctioning. Lavage and suctioning can still be used, although this should be left to the discretion of the respiratory therapist. 
9. The head of bed should be raised 45 degrees at all times to prevent aspiration of stomach contents. This should be started as soon as possible, and may even be started in the emergency room prior to the patient being transferred or admitted to critical care.
10. A feeding tube should be inserted to assure adequate nutrition. 
11. The mouth should be washed with a Chlorhexidine Oral Rinse and suctioned out every two hours (as appropriate). Studies have shown a good mouth cleansing can greatly reduce the chance of VAP.
12. Do not use heat and moisture exchangers unless absolutely necessary, such as when you need to transfer the patient. Studies have shown HMEs tend to increase likelihood of VAP.
13. Sedatives should be limited. There have been a lot of studies and discussions on the use of sedatives on intubated patients. Some suggest limiting sedation in the morning to make sure the patient is awake, cooperative, and understands the plan. Ideally, sedatives should be stopped at least four hours prior to beginning any weaning screen.
14. Studies show that it is most effective if the circuit is changed weekly, as opposed to daily as the best way of preventing VAP.
15. Daily chest-x-ray to monitor for signs of pneumonia
16. Sterile technique and proper technique when inserting lines. We are all instructed to monitor physicians to make sure they use this proper technique.
17. Stress-ulcer prophylaxis (this would be part of the ventilator bundle, and would be a nursing protocol. Ours includes a daily proton pump inhibitor like Prilosec (omeprazole)
18. Prophylactic antibiotic therapy (of course there is controversy here too). This is to prevent infections such as pneumonia and sepsis. 

These are some ideas that have been researched over and over the past several years. Newer studies are changing some of the older ideas we had regarding intubation. For instance, back in 1997 when I attended RT school, we were taught never to exceed a cuff pressure of 24 cwp to prevent the occlusion of blood flow. So, as you can see, this has changed considerably, although it's supposedly all for the better. 

Intubation and mechanical ventilation is not a science: it is an art based on a science. So, as you will learn (or have learned) in this profession, we do the best we can with what we know today, and as we learn more we do better. This is the case with advancements in intubation and extubation, as it is in other areas of healthcare.