ANWICU knowledge

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2 Subglottic Secretion Drainage

3 Muscedere Meta-Analysis Crit Care Med 2011 Essentially a follow up from the Dezfulian 2005 Metaanalysis (Am J Med) 13 trials included (adults only) 2400 patients Strengths: Included only RCTs Conservative analytical methods Conducted sensitivity analyses

4 Weaknesses: Varying inclusion and exclusion criteria and different populations in the underlying studies The extent of the use of other VAP reducing techniques is unclear Differing methods of VAP confirmation Continuous vs intermittent suction Overall risk ratio for ventilator associated pneumonia was 0.55 (95% confidence interval, ; p <.00001)

5 The use of subglottic secretion drainage was also associated with: reduced intensive care unit length of stay (-1.52 days; 95% confidence interval, to -0.11; p =.03) decreased duration of mechanical ventilation (-1.08 days; 95% confidence interval, to -0.12; p =.03) increased time to first episode of ventilator associated pneumonia (2.66 days; 95% confidence interval, ; p= 001) There was no effect on hospital or intensive care unit mortality.

6 Ventilator Associated Pneumonia What is a VAP? Ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or longer after mechanical ventilation is given by means of an endotracheal tube or tracheostomy. It may be classed as early or late onset Early hrs Late >72 hrs Kollef 1999 NEJM review article Early <96 hrs Late >96hrs Craven 2000 Chest

7 VAP is the most frequent infection occurring in patients after admission to ICU 25% of patients develop an ICU-acquired infection; respiratory accounted for 80% of these Sepsis in European intensive care units: Results of the SOAP study Crit Care Med 2006 The attributable mortality of VAP continues to be debated VAP can be linked with increased duration of ventilation, ICU and hospital length of stay, and significantly increased costs Prevention of VAP is possibly one of the most cost-effective interventions currently attainable in the ICU

8 Causative organisms Early Late Staph Aureus Psuedomonas Aeruginosa Haemophilus influenzae Acinetobacter spp Strep Pneumoniae Enterobacter spp Moraxella catarrhalis, MRSA

9 ESKAPE pathogens E E Coli S S Aureus / Serratia sp K Klebsiella Pneumonia A Acinetobacter Baumannii P Pseudomonas Aeruginosa / Proteus sp E Enterococcus Faecium The above organisms account for >80% of VAPs

10 2007 DoH High Impact Intervention Care Bundle Elevation of the head of the bed (30-45 o ) Sedation level assessment (daily sedation hold) Oral hygiene (2% chlorhex 6 hourly) Subglottic aspiration 1-2 hourly (if expected to be ventilated for >72 hrs) Tracheal tube cuff pressure (measured 4 hourly, maintained between 20-30cm H 2 O) Stress ulcer prophylaxis prescribed only to high-risk patients (reviewed daily)

11 2008 NICE / NPSA recommendations Position patients in a semi-recumbent or seated position for as much of the time as possible. Include oral antiseptics (chlorhexidine) as part of the oral hygiene regimen for all patients who are intubated and receiving mechanical ventilation.

12 Other considerations Avoid unnecessary ETT changes Orotracheal intubation over nasotracheal intubation Continuous aspiration of subglottic secretions Enteral feeding with post-pyloric feeding tube Standard infection control measures Sucralfate or H 2 blockers over proton pump inhibitors for stress ulcer prophylaxis

13 Suspecting a VAP

14 Clinical Pulmonary Infection Score Temp score score 1 >39.0 or <36.5 score 2 WCC 4 11: score 0 <4 or >11: score1 <4 or >11 with >50% band form: score2 Secretions Scant: score 0 Non-purulent: score 1 Purulent: score 2

15 CPIS 2 PaO2 / FiO2 >240, ARDS or contusion: score 0 <240 and no ARDS: score 2 CXR No infiltrate: score 0 Diffuse infiltrate: score 1 Patchy infiltrate: score 2 A Score of 6+ should get a BAL or mini-bal

16 CIPS 3 Originally intended to help differentiate between VAP and pulmonary colonization Can be used to assist in the clinical diagnosis of VAP Using CPIS results in fewer missed VAPs However, can also lead to overtreatment

17 Sputum Confirmation of a VAP

18 Culture techniques Tracheal Aspirate (TA) least invasive method; organisms from the biofilm coating the ETT or trachy may contaminate the culture; sensitive not specific. Quantitative cultures rarely performed. Bronchoalveolar Lavage (BAL) A fiberoptic bronchoscope is directed to the area of concern within the lung, which is flushed with sterile fluid. The fluid and specimen it carries with it are then suctioned, collected and cultured. BAL may be both diagnostic and therapeutic. Quantitative cultures are usually obtained. The large volume of the specimen makes it useful for detecting non- bacterial pathogens

19 Culture techniques 2 Mini-BAL (Non-Bronchoscopic Bronchoalveolar Lavage) A specialized catheter is inserted into the ETT. A telescoping catheter system protects the end of the catheter from contamination during insertion. The catheter is advanced approx 30cm and the inner cannula is then gently advanced until it meets resistance. 30mL of sterile saline is injected and suctioned. This is repeated a second time and the combined aspirate sent for culture. Semiquantitative or quantitative cultures are usually performed.

20 Culture techniques 3 Protected Brush Specimens (PBS) A specialized catheter containing a brush is either blindly advanced until gentle resistance is met or inserted during bronchoscopy. When the area to be sampled is found, the brush is pushed through a plug and a sample obtained by gentle scraping. The brush is retracted, the catheter or bronchoscope is removed, and a quantitative culture is obtained. Because the sample is low volume, it is not appropriate for detection of non-bacterial pathogens. Results are less sensitive, but more specific than BAL.

21 Quantitative culture thresholds for the diagnosis of VAP TA: a threshold of more than 1,000,000 colony forming units (cfu)/ml is accepted as positive BAL: a value of 100,000 cfu/ml is gaining clinical acceptance Mini-BAL: a threshold of more than 10,000 cfu/ml is considered positive For PBS, a threshold of more than 1000 cfu/ml is considered positive.