Positive Airway Pressure at Extubation Minimizes Subglottic Secretion Leak In Vitro

Accumulated secretion above the endotracheal tube cuff can be aspirated during extubation after deflation. The possible techniques for minimizing pulmonary aspiration from subglottic secretion during extubation have not been well explored. This study aimed to determine the effect of different extubation techniques on secretion leakage. An endotracheal tube was placed in a tube mimicking an airway. We measured the leak volume of water or artificial sputum of different viscosities with three extubation techniques—negative pressure with suctioning; positive pressure with a resuscitator; and continuous positive airway pressure set at 5, 10, and 20 cm H2O. Extubation with continuous positive airway pressure resulted in lower secretion leakage than that with negative pressure with suctioning and positive pressure with a resuscitator. Increasing the continuous positive airway pressure level decreased secretion leakage volume during extubation. We further determined a correlation of leak volume with sputum viscosity. Continuous positive airway pressure at 5 cm H2O produced lower volume secretion leakage than the other two techniques, even with higher secretion viscosity. Based on these results, using continuous positive airway pressure with a previous ventilator continuous positive airway pressure/positive end-expiratory pressure setting for extubation is recommended.

Rapid-flow expulsion maneuver in subglottic secretion clearance to prevent ventilator-associated pneumonia: a randomized controlled study

Background Following endotracheal intubation, clearing secretions above the endotracheal tube cuff decreases the incidence of ventilator-associated pneumonia (VAP); therefore, subglottic secretion drainage (SSD) is widely advocated. Our group developed a novel technique to remove the subglottic secretions, the rapid-flow expulsion maneuver (RFEM). The objective of this study was to explore the effectiveness and safety of RFEM compared with SSD. Methods This study was a single-center, prospective, randomized and controlled trial, conducted at Respiratory Intensive Care Unit (ICU) of Beijing Chao-Yang Hospital, a university-affiliated tertiary hospital. The primary outcome was the incidence of VAP, assessed for non-inferiority. Results Patients with an endotracheal tube allowing drainage of subglottic secretions (n = 241) were randomly assigned to either the RFEM group (n = 120) or SSD group (n = 121). Eleven patients (9.17%) in the RFEM group and 13 (10.74%) in the SSD group developed VAP (difference, − 1.59; 95% confidence interval [CI] [− 9.20 6.03]), as the upper limit of 95% CI was not greater than the pre-defined non-inferiority limit (10%), RFEM was declared non-inferior to SSD. There were no statistically significant differences in the duration of mechanical ventilation, ICU mortality, or ICU length of stay and costs between groups. In terms of safety, no accidental extubation or maneuver-related barotrauma occurred in the RFEM group. The incidence of post-extubation laryngeal edema and reintubation was similar in both groups. Conclusions RFEM is effective and safe, with non-inferiority compared to SSD in terms of the incidence of VAP. RFEM could be an alternative method in first-line treatment of respiratory ICU patients. Trial registration This study has been registered on ClinicalTrials.gov (Registration Number: NCT02032849, https://clinicaltrials.gov/ct2/show/NCT02032849); registered on January 2014

Promoting subglottic secretion drainage: a quality improvement project in a UK critical care unit

The aim of the study was to promote the practice of subglottic secretion drainage (SSD) in a UK critical care unit. SSD is a technique employed to reduce microaspiration of oropharyngeal secretions in patients with cuffed endotracheal airways. Aspiration of oropharyngeal secretions is the accepted cause of the majority of ventilator-associated pneumonia (VAP), a complication of invasive ventilation with high associated mortality. The plan–do–study–act methodology was employed. The local critical care patient database was searched for patients requiring mechanical ventilation via a tracheostomy tube with subglottic port in the 3 months prior to intervention. Patient records were interrogated for evidence of the practice of SSD. The intervention involved the introduction of a tracheostomy care bundle to be prescribed on insertion of a tracheostomy on the critical care unit, in combination with departmental teaching. The bundle included prompts for nursing staff to practise regular SSD and to complete a tracheostomy care plan at the end of shift. A total of 24 patients were included. A review of practice was conducted every 3 months for 1 year. This showed an improvement in documented evidence of SSD from 0% of days at baseline to 85.7% of days at 1 year. Implementation of a tracheostomy order set prescribing regular SSD resulted in an improvement in the practice of SSD in patients ventilated via tracheostomy. This has implications for patient outcomes and healthcare costs, given that SSD has been shown to reduce incidence of VAP.

Rapid-Flow Expulsion Maneuver in Subglottic Secretion Clearance to Prevent Ventilator-Associated Pneumonia: A Randomized Controlled Study

Background: Following endotracheal intubation, clearing secretions above the endotracheal tube cuff decreases the incidence of ventilator-associated pneumonia (VAP); therefore, subglottic secretion drainage (SSD) is widely advocated. Our group developed a novel technique to remove the subglottic secretions, the rapid-flow expulsion maneuver (RFEM). The objective of this study is to explore the effectiveness and safety of RFEM compared with SSD.Methods: This study was a single center, prospective, randomized and controlled trial, conducted at Respiratory Intensive Care Unit (ICU) of Beijing Chao-Yang Hospital, a university-affiliated tertiary hospital. The primary outcome was the incidence of VAP, assessed for non-inferiority.Results: Patients with an endotracheal tube allowing drainage of subglottic secretions (n=241) were randomly assigned to either the RFEM group (n=120) or SSD group (n=121). Eleven patients (9.17%) in the RFEM group and 13 (10.74%) in the SSD group developed VAP (difference, -1.59; 95% confidence interval [CI], [-9.20 6.03]), as the upper limit of 95% CI was not greater than pre-defined non-inferiority limit(10%), RFEM was declared non-inferior to SSD. There were no statistically significant differences in the duration of mechanical ventilation, ICU mortality, or ICU length of stay and costs between groups. In terms of safety, no accidental extubation or maneuver-related barotrauma occurred in the RFEM group. The incidence of post-extubation laryngeal edema and reintubation was similar in both groups.Conclusions: RFEM is effective and safe, with non-inferiority compared to SSD in terms of the incidence of VAP. RFEM could be an alternative method in first-line treatment of respiratory ICU patients. Trial registration: This study has been registered on ClinicalTrials.gov (registration number: NCT02032849, https://clinicaltrials.gov/ct2/show/NCT02032849); registered on January 2014.

Impact of Each Component of a Ventilator Bundle on Preventing Ventilator-Associated Pneumonia and Lower Respiratory Infection

Background: Ventilator-associated lower respiratory infections (LRIs) and pneumonia (VAP) are important healthcare-associated infections and are among the leading causes of death worldwide. Prevention of these infections are often based on care bundles. We investigated the incidence of VAP+LRI and the preventive efficacy of each component of our ventilator bundle. Methods: Our ventilator bundle includes 6 components that are daily checked by an infection control practitioner. These 6 evidence-based practices were implemented in 3 ICUs from a general tertiary-care private hospital in Belo Horizonte City (Brazil): (1) daily oral care with chlorhexidine; (2) elevate the head of the bed to between 30 and 45; (3) avoid scheduled ventilator circuit change; (4) monitor cuff pressure; (5) use subglottic secretion drainage; and (6) daily sedation interruption and daily assessment of readiness to extubate. VAP and ventilator-LRI definitions were obtained from the CDC NHSN. The impact of adherence rate to items in the ventilator bundle (%) on the incidence rate of VAP+LRI was assessed using linear regression and scatterplot analyses. Results: Between January 2018 and April 2019, 1,888 ventilator days were observed in the 3 ICUs, with 42 VAP and LRI events, an overall incidence rate of 22.2 cases per 1,000 ventilator days. After September 2018, the infection control service started a campaign to increase the ventilator bundle compliance (Fig. 1). Adherence rates to all 6 bundle components increased between January–August 2018 and September 2018–April 2019 from 25% to 55% for daily oral care, from 34% to 79% for elevating the head of the bed, 28% to 86% for avoiding scheduled ventilator circuit change, from 32% to 83% for cuff pressure monitoring, from 32% to 83% for subglottic secretion drainage, and from 33% to 85% for daily sedation interruption. PAV and LRI incidence decreased from 41 to 16 in ICU A, from 22 to 14 in ICU B and from 24 to 18 in ICU C. The impact of each bundle component was identified by linear regression, calculating the percentage of PAV+LRI incidence rate that is explained by bundle item adherence (r2) and correlation coefficient (r): daily sedation interruption (r2 = 48%; r = 0.69; P = .004) (Fig. 2), cuff pressure monitorization (r2 = 0.3721; r = 0.61; P = .016), subglottic secretion drainage (r2 = 36%; r = 0.60; P = .017), avoidance of scheduled ventilator circuit change (r2 = 34%; r = 0.58; P = .023), daily oral care (r2 = 25%; r = 0.50; P = .050), and elevate the head of the bed (r2 = 25%; r = 0.48; P = .067). Conclusions: The impact of each bundle component on preventing PAV+LRI was identified by the study. An educational intervention performed by the infection control service increased the adherence to the ventilator bundle, and the PAV and LRI incidence decreased.Funding: NoneDisclosures: None