Secretion management in the mechanically ventilated patient

Secretion management in the mechanically ventilated patient includes routine methods for maintaining mucociliary function, as well as techniques for secretion removal. Humidification, mobilization of the patient, and airway suctioning are all routine procedures for managing secretions in the ventilated patient. Early ambulation of the post-surgical patient and routine turning of the ventilated patient are common secretion-management techniques that have little supporting evidence of efficacy. Humidification is a standard of care and a requisite for secretion management. Both active and passive humidification can be used. The humidifier selected and the level of humidification required depend on the patient's condition and the expected duration of intubation. In patients with thick, copious secretions, heated humidification is superior to a heat and moisture exchanger. Airway suctioning is the most important secretion removal technique. Open-circuit and closed-circuit suctioning have similar efficacy. Instilling saline prior to suctioning, to thin the secretions or stimulate a cough, is not supported by the literature. Adequate humidification and as-needed suctioning are the foundation of secretion management in the mechanically ventilated patient. Intermittent therapy for secretion removal includes techniques either to simulate a cough, to mechanically loosen secretions, or both. Patient positioning for secretion drainage is also widely used. Percussion and postural drainage have been widely employed for mechanically ventilated patients but have not been shown to reduce ventilator-associated pneumonia or atelectasis. Manual hyperinflation and insufflation-exsufflation, which attempt to improve secretion removal by simulating a cough, have been described in mechanically ventilated patients, but neither has been studied sufficiently to support routine use. Continuous lateral rotation with a specialized bed reduces atelectasis in some patients, but has not been shown to improve secretion removal. Intrapulmonary percussive ventilation combines percussion with hyperinflation and a simulated cough, but the evidence for intrapulmonary percussive ventilation in mechanically ventilated patients is insufficient to support routine use. Secretion management in the mechanically ventilated patient consists of appropriate humidification and as-needed airway suctioning. Intermittent techniques may play a role when secretion retention persists despite adequate humidification and suctioning. The technique selected should remedy the suspected etiology of the secretion retention (eg, insufflation-exsufflation for impaired cough). Further research into secretion management in the mechanically ventilated patient is needed.     

Cough assist strategy for pulmonary toileting in ventilator-dependent spinal cord injured patients.

The limited innervation of muscles supporting pulmonary functioning in spinal cord injured (SCI) patients indicates that these individuals are at a particularly high risk for atelectasis and other sequelae of ventilator dependency. As an alternative strategy to endotracheal suctioning for secretion management, our acute rehabilitation facility utilizes an assistive cough device. This device has not been commonly utilized in the SCI population, and studies concerning this device have primarily focused on individuals with neuromuscular diseases. In our experience, utilization of mechanical in-exsufflation has produced positive outcomes in terms of patient satisfaction, low rates of ventilator-acquired pneumonia, low incidence of complications, and ease of home discharge with patient or family using the device long term. This article describes the device, as well as the protocols associated with its use in one ventilator spinal cord center.     

改良式拍背吸痰在呼吸机治疗重症肺炎患儿中的疗效研究

目的探讨改良式拍背后吸痰在婴幼儿重症肺炎应用呼吸机患儿治疗中的疗效。方法选择应用呼吸机治疗的小儿重症肺炎60例,随机分成对照组30例和实验组30例。实验组采用改良式拍背后吸痰,对照组采用常规式拍背后吸痰,比较两组患儿吸痰前后血氧分压（PaO2）、二氧化碳分压（PaCO2）的变化及临床疗效。结果两组患儿吸痰前PaO2、PaCO2的差异无统计学意义（P〉0．05）;吸痰后实验组PaO2（58．57±12．41）mmHg,PaCO2（42．76±10．51）mmHg,对照组PaO2（51．31±12．32）minHg,PaC02（48．98±9．86）mmHg,实验组吸痰前后血气测定的改善情况优于对照组,疗效优于对照组,差异均有统计学意义（P〈0．05）。结论采用改良式拍背后吸痰,能明显缩短重症肺炎的患儿使用呼吸机的时间及病程,提高了小儿重症肺炎的治愈率。     

Incidence of colonization, nosocomial pneumonia, and mortality in critically ill patients using a Trach Care closed-suction system versus an open-suction system: prospective, randomized study

Eighty-four intubated, mechanically ventilated patients were prospectively evaluated for incidences of colonization and nosocomial pneumonias dependent on whether they received endotracheal suctioning by an "open" suction method vs. "closed" suction (Trach Care Closed Suction System) method. Results show that closed suctioning is associated with a significant (67% vs. 39% p less than .02) increase in colonization compared with open suctioning. However, difference in the incidence of nosocomial pneumonia was not significantly (26% vs. 29%) different between closed and open suctioning. Differences in severity of illness (Acute Physiology and Chronic Health Evaluation II and Therapeutic Intervention Scoring System), age, sex, presence of NG tubes, use of H2 antagonists or antacids, use of antibiotics, and history of smoking were all nonsignificant. Survival analysis demonstrated that the probability of survival without developing nosocomial pneumonia was greater among closed-suctioning patients vs. open-suctioned patients (p less than .03). This study shows that suctioning performed via the Trach Care closed-suction system increases the incidence of colonization but not the incidence of nosocomial pneumonia, and may actually decrease mortality when compared with open-suction systems.     

Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention

BACKGROUND: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients. PURPOSE: To develop evidence-based guidelines for the prevention of VAP. DATA SOURCES: MEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials. STUDY SELECTION: The authors systematically searched for all relevant randomized, controlled trials and systematic reviews on the topic of prevention of VAP in adults that were published from 1980 to October 1, 2006. DATA EXTRACTION: Independently and in duplicate, the panel scored the internal validity of each trial. Effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. Scores for the safety, feasibility, and economic issues were assigned based on consensus of the guideline panel. LEVELS OF EVIDENCE: The following statements were used: recommend, consider, do not recommend, and no recommendation due to insufficient or conflicting evidence. DATA SYNTHESIS: To prevent VAP: We recommend: that the orotracheal route of intubation should be used for intubation; a new ventilator circuit for each patient; circuit changes if the circuit becomes soiled or damaged, but no scheduled changes; change of heat and moisture exchangers every 5 to 7 days or as clinically indicated; the use of a closed endotracheal suctioning system changed for each patient and as clinically indicated; subglottic secretion drainage in patients expected to be mechanically ventilated for more than 72 hours; head of bed elevation to 45 degrees (when impossible, as near to 45 degrees as possible should be considered). Consider: the use of rotating beds; oral antiseptic rinses. We do not recommend: use of bacterial filters; the use of iseganan We make no recommendations regarding: the use of a systematic search for sinusitis; type of airway humidification; timing of tracheostomy; prone positioning; aerosolized antibiotics; intranasal mupirocin; topical and/or intravenous antibiotics. CONCLUSION: There are a growing number of evidence-based strategies for VAP prevention, which, if applied in practice, may reduce the incidence of this serious nosocomial infection.     

A comparison of two airway suctioning frequencies in mechanically ventilated, very-low-birthweight infants.

INTRODUCTION: Endotracheal suctioning of mechanically ventilated, very-low-birthweight infants for removal of respiratory secretions can be associated with morbidity. Routine endotracheal suctioning is inadvisable, but the safe minimum endotracheal suctioning frequency for prevention of airway obstruction has not been determined. HYPOTHESIS: Decreasing suctioning frequency from every 4 hours to every 8 hours (plus as needed) would have no clinically important effect on the primary outcomes (nosocomial bloodstream infection [BSI], ventilator-associated pneumonia [VAP], and bacterial airway colonization) or secondary outcomes (reintubation rates, need for postural drainage, severity of bronchopulmonary dysplasia [BPD], neonatal mortality, duration of mechanical ventilation, and duration of hospitalization). METHODS: We conducted a sequential retrospective study of 90 very-low-birthweight infants who were mechanically ventilated for longer than 7 days and who underwent endotracheal suctioning every 4 hours (plus as needed) and 90 similar infants who underwent endotracheal suctioning every 8 hours (plus as needed). Two-pass endotracheal suctioning used during the study period required predetermined measurement of the suction catheter and prior instillation of saline. RESULTS: The 2 treatment groups were similar in demographic and clinical characteristics, including survival (90% and 85%), age at time of death (28 and 33 d), mean birthweight (926 and 934 g), gestational age (27 and 27 wk), duration of ventilation (29 and 27 d), and duration of stay (55 and 53 d). Regardless of suctioning frequency, airway colonization with Gram-positive cocci occurred in the majority of patients by 2 weeks of life. Forty-three percent of the infants suctioned every 4 hours and 44% of those suctioned every 8 hours became airway colonized with Gram-negative bacilli. No Gram-negative bacilli species was more likely to be associated with either treatment group. VAP was diagnosed in 5 of the infants suctioned every 4 hours and in 9 of the infants suctioned every 8 hours. Nosocomial BSI occurred in 18 of the infants suctioned every 4 hours and in 21 of the infants suctioned every 8 hours. The difference in incidence of VAP and BSI was due to a epidemic that started before the change in suctioning frequency. During hospitalization, approximately one fourth of the patients in each group required postural drainage and were reintubated 11 and 10 times per 100 ventilator days, respectively. A comparable number of infants in each group developed severe BPD and were discharged home on oxygen. Suctionings per patient per ventilator day were 6 for the group suctioned every 4 hours and 4 for the group suctioned every 8 hours (p < 0.01). CONCLUSIONS: A low-frequency suctioning regimen (every 8 hours plus as needed) can be implemented without increasing the incidence of nosocomial BSI, VAP, bacterial airway colonization, frequency of reintubation, need for postural drainage, severity of BPD, neonatal mortality, duration of mechanical ventilation, or duration of hospitalization. Although the minimum suctioning frequency for removal of unwanted respiratory secretions is yet to be established, a substantial reduction in endotracheal suctioning frequency appears to be safe.     

Ventilator circuit and secretion management strategies: a Franco-Canadian survey

OBJECTIVE: To determine the use of ventilator circuit and secretion management strategies in France and Canada. DESIGN: Binational cross-sectional survey. POPULATION: Intensive care unit (ICU) directors in French and Canadian university hospitals. MEASUREMENTS: We compared responses between countries regarding the use of seven circuit and secretion strategies, the rationales against their use, decisional responsibility for these strategies, whether ventilator-associated pneumonia (VAP) practice was audited, and whether VAP prevention guidelines addressing these strategies were used. RESULTS: The response rate was 72/84 (85.7%) for French and 31/32 (96.9%) for Canadian ICUs. Endotracheal intubation was predominantly oral in both countries. Changing the ventilator circuits only for every new patient was more frequent in France than in Canada (p < .0001). Heated humidifiers were used more in Canada than France (p = .0003). Closed endotracheal suctioning was used more frequently in Canada (p < .0001). In both countries, subglottic secretion drainage and kinetic beds were rarely used. Semirecumbent positioning was reported more often by French than Canadian ICUs (p = .003). Reasons for nonuse of these strategies included adverse effects (heat and moisture exchangers), cost (kinetic beds), lack of convincing benefit (subglottic secretion drainage), and nurse inconvenience (semirecumbency). Decisional responsibility for each strategy differed among institutions. VAP prevention practice was periodically reviewed in 53% of French and 68% of Canadian ICUs (p = .20). VAP prevention guidelines were used in 64% and 30% of these ICUs, respectively (p = .002). CONCLUSIONS: Our study does not support the notion that published recommendations substantially impact reported use of several ventilator circuit and secretion management strategies. Based on the use of more frequent ventilator circuit changes, closed suctioning systems, heated humidifiers, and respiratory therapists, ventilator circuit and secretion management practice appears more costly in Canada than in France.     

Effects of decreasing the frequency of ventilator circuit changes to every 7 days on the rate of ventilator-associated pneumonia in a Beijing hospital

INTRODUCTION: We investigated whether decreasing ventilator circuit changes from every 2 days to every 7 days would impact ventilator-associated pneumonia rates at our institution. METHODS: All mechanically ventilated patients at Peking Union Medical College Hospital were studied over a 21 month period. From March 1998 to February 1999, ventilator circuits were changed every 2 days, and from June through December 1999, ventilator circuits were changed every 7 days. Nosocomial pneumonia was identified using the criteria of the Centers for Disease Control. RESULTS: In the 2-day-change group, there were 2,277 ventilator-patient days and 38 patients developed pneumonia, resulting in a pneumonia rate of 16.7 cases per 1,000 ventilator days. The 7-day-change group accumulated 972 ventilator days and 8 patients contracted pneumonia, resulting in a pneumonia rate of 8.2 cases per 1,000 ventilator days. The pneumonia rate was significantly lower in the 7-day-change group (p = 0.007). To standardize for seasonal variability, we compared results from the same seasonal time frames (June to December 1998 for the 2-day-change group, and June to December 1999 for the 7-day-change group), and obtained similar findings: during those periods, pneumonia rates were 24.2 cases per 1,000 ventilator days for the 2-day-change group and 8.9 cases per 1,000 ventilator days for the 7-day-change group (p = 0.001). CONCLUSIONS: A circuit change interval of 7 days had a lower risk of ventilator-associated pneumonia than a 2-day change interval. Therefore, ventilator circuits can be safely changed every 7 days in our setting.     

Endotracheal Tube Suctioning in the Newborn: A Review of the Literature

Maintaining the patency of the endotracheal tube (ETT) is crucial to effective ventilation and oxygenation of the patient receiving assisted ventilation. Performed frequently in the NICU, ETT suctioning has not received extensive study in this population. However, the deleterious effects of this procedure in the newborn are well documented. Methods to reduce these effects include suctioning only as needed instead of using a routine schedule, shallow (or measured) suctioning to avoid trauma to the carina, and closed systems for suctioning in which ventilator pressure is mostly maintained throughout the procedure. Overall, there is limited scientific evidence to guide practice related to ETT suctioning in the newborn, and unit protocols and clinician practices vary. This article will review the current literature regarding ETT suctioning in the newborn and summarize recommendations for best practice.     

运动神经元病患者8年呼吸机治疗的气道护理

目的报告1例运动神经元病经呼吸机治疗8年的气道管理。方法采用个性化的吸痰方法,通过膨肺技术增加肺的顺应性、呼吸肌功能锻炼预防肺不张等。结果预防了呼吸机相关性肺炎发生。结论长期机械通气的患者,采用膨肺技术和有效的呼吸机治疗、护理措施,可预防肺不张和呼吸机相关性肺炎。     

Prevention of hospital-associated pneumonia and ventilator-associated pneumonia

OBJECTIVE: To synthesize the available clinical data for the prevention of hospital-associated pneumonia (HAP) and ventilator-associated pneumonia (VAP) into a practical guideline for clinicians. DATA SOURCE: A Medline database and references from identified articles were used to perform a literature search relating to the prevention of HAP/VAP. CONCLUSIONS: There is convincing evidence to suggest that specific interventions can be employed to prevent HAP/VAP. The evidence-based interventions focus on the prevention of aerodigestive tract colonization (avoidance of unnecessary antibiotics and stress ulcer prophylaxis, use of sucralfate for stress ulcer prophylaxis, chlorhexidine oral rinse, selective digestive decontamination, short-course parenteral prophylactic antibiotics in high-risk patients) and the prevention of aspiration of contaminated secretions (preferred oral intubation, appropriate intensive care unit staffing, avoidance of tracheal intubation with the use of mask ventilation, application of weaning protocols and optimal use of sedation to shorten the duration of mechanical ventilation, semirecumbent positioning, minimization of gastric distension, subglottic suctioning, avoidance of ventilator circuit changes/manipulation, routine drainage of ventilator circuit condensate). Clinicians caring for patients at risk for HAP/VAP should promote the development and application of local programs encompassing these interventions based on local resource availability, occurrence rates of HAP/VAP, and the prevalence of infection due to antibiotic-resistant bacteria (Pseudomonas aeruginosa, Acinetobacter species, and methicillin-resistant Staphylococcus aureus).     

Closed suctioning system: Critical analysis for its use

Aim:  To determine the efficacy and effectiveness of the closed suctioning system.
Method:  Literature review articles were accessed from the following databases: PubMed, EMBASE, CINAHL, and Cochrane Library. The literature review criteria included: all publication styles except meta-analysis, participants that were ≥18 years, written in English, and published between 1973 and 2008.
Results:  This literature review revealed that the efficacy and effectiveness of the closed suctioning system remains to be demonstrated. The device manufacturers' studies focused on cost reduction, cross-contamination, and preservation of the oxygen saturation of patients during endotracheal suctioning; however, the clinical studies focused on the use of closed suctioning systems to prevent ventilator-associated pneumonia. The reviewed studies had small sample sizes with heterogeneous demographics and non-randomized controls. Recent studies suggest that closed suctioning systems are no better than open suctioning systems in terms of mortality, morbidity, or the cost-benefit ratio. A few studies did indicate that the closed suctioning system might reduce the loss of lung volume and oxygen desaturation.
Conclusion:  The studies reviewed in this article suggest that the evidence on the efficacy and effectiveness of closed suctioning systems is inconclusive. Only limited populations will benefit clinically from the use of this device. There is a need for further studies with randomized controlled trials to explore the use of closed suction systems and to update current clinical practise guidelines.     

Care of the ventilator circuit and its relation to ventilator-associated pneumonia

Ventilator circuits should not be changed routinely for infection control purposes. The maximum duration of time that circuits can be used safely is unknown. Evidence is lacking related to ventilator-associated pneumonia (VAP) and issues of heated versus unheated circuits, type of heated humidifier, method for filling the humidifier, and technique for clearing condensate from the ventilator circuit. Although the available evidence suggests a lower VAP rate with passive humidification than with active humidification, other issues related to the use of passive humidifiers (resistance, dead space volume, airway occlusion risk) preclude a recommendation for the general use of passive humidifiers. Passive humidifiers do not need to be changed daily for reasons on infection control or technical performance. They can be safely used for at least 48 hours, and with some patient populations some devices may be able to be used for periods of up to 1 week. The use of closed suction catheters should be considered part of VAP prevention strategy, and they do not need to be changed daily for infection control purposes. The maximum duration of time that closed suction catheters can be used safely is unknown. Clinicians caring for mechanically ventilated patients should be aware of risk factors for VAP (eg, nebulizer therapy, manual ventilation, and patient transport).     

集束化干预策略在预防ICU呼吸机相关性肺炎中的应用

目的探讨集束化干预策略在胸外科术后机械通气患者呼吸机相关性肺炎（VAP）预防中的应用效果。方法选择2007年1月至2008年12月胸外科术后机械通气患者共81例为对照组,2009年1月至2011年11月胸外科术后机械通气患者共109例为干预组。对照组给予常规护理;干预组除实施常规护理外,实行集束化干预策略,包括半卧位（抬高床头30～45°）、密闭式吸痰、持续声门下吸引、严格执行手卫生、每日唤醒并进行拔管评估、早期肠内营养、预防深静脉血栓及消化性溃疡等措施。分析两组VAP发生率。结果干预组VAP发生率为8.26％,明显低于对照组20.99％,差异有统计学意义（χ2=6.376,P＜0.05）。结论在胸外科术后机械通气患者治疗期间,实行呼吸机集束化干预策略能有效降低VAP发生率,值得临床推广应用。     

The safety and efficacy of sustained inflations as a lung recruitment maneuver in pediatric intensive care unit patients

Objective To assess the safety and efficacy of sustained inflations (SI) as lung recruitment maneuvers (RMs) in ventilated pediatric intensive care unit (PICU) patients. Design Observational, prospective data collection. Setting Tertiary-care PICU. Patients and participants Thirty-two consecutive ventilated pediatric patients. Interventions An SI (30–40 cmH₂O for 15–20 s) was performed following a ventilator disconnection, suctioning, hypoxemia, or routinely every 12 h. Physiologic variables were recorded for 6 h after each SI. All other management was at the attending physician's discretion. The change in variables from pre-SI to post-SI (at 2, 10, and 15 min, 1, 2, 3, 4, 5, and 6 h) was compared using mixed models to account for repeated measures in the same patient. Measurements and results 93 RMs were performed on 32 patients (ages 11 days to 14 years). RMs were done after suctioning (58/93, 62%), ventilator disconnect (5/93, 5%), desaturation (8/93, 9%), or routinely (22/93, 24%). Seven of 93 RMs (7.5%) were interrupted for patient agitation, and 2/93 (2.2%) for transient bradycardia. There was no evidence of statistically significant changes in systolic blood pressure, heart rate, or oxygen saturation as measured by pulse oximetry from pre-RM to post-RM, and there were no air leaks. In three patients with altered intracranial compliance, three of eight RM were associated with a spike of intracranial pressure. There was a sustained significant decrease in FiO₂ by 6.1% lasting up to 6 h post-RM. Conclusions RMs (as SI) are safe in ventilated PICU patients and are associated with a significant reduction in oxygen requirements for the 6 h after the RM. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Suctioning through a double-lumen endotracheal tube helps to prevent alveolar collapse and to preserve ventilation

Objective

Endotracheal suctioning can cause alveolar collapse and impede ventilation. One reason is the gas flow through a single-lumen endotracheal tube (ETT) provoking a gradient between airway opening and tracheal (P_tr) pressures. Separately extending the patient tubing limbs of a suitable ventilator into the trachea via a double-lumen ETT should maintain P_tr. Can this technique reduce the side effects?

Design and setting

Bench and animal studies in a university hospital laboratory.

Interventions

A lung model was ventilated via single and double-lumen ETTs. Closed-system suctioning was applied with catheters introduced into the single-lumen ETT or the expiratory lumen of the double-lumen ETT via swivel adapter. Seven anesthetized pigs (lungs lavaged) underwent three runs of ventilation and suctioning through (a, b) an 8.0-mm ID single-lumen ETT, (c) a double-lumen ETT (41Ch outer diameter, OD). In (a) the single-lumen ETT was disconnected for suctioning, in (b) and (c) ventilator mode was set to continuous positive airway pressure mode, and the ETTs remained connected.

Measurements and results

Bench: Suction through single-lumen ETTs impaired ventilation and led to strongly negative P_tr (common: ?10 to ?20 mbar); the double-lumen ETT technique maintained ventilation and pressures. Animals: Lung gas content (computed tomography, n=4) and arterial oxygen partial pressure, initially 1462±65 ml/532±76 mmHg, were significantly reduced by suctioning through single-lumen ETT: to 302±79 ml/62±6 mmHg with disconnection and to 851±211 ml/158±107 mmHg with closed suction. With double-lumen ETT they remained at 1377±95 ml/521±56 mmHg.

Conclusions

The double-lumen ETT technique minimizes side effects of suctioning by maintaining P_tr.     

Endotracheal suctioning with or without instillation of isotonic sodium chloride solution in critically ill children.

BACKGROUND: Instillation of isotonic sodium chloride solution for endotracheal tube suctioning is controversial. Research has focused on the effect of such instillation in adults; no studies in children have been published. OBJECTIVES: (1) To describe differences in oxygen saturation depending on whether or not isotonic sodium chloride solution is instilled during suctioning and (2) to describe the rates of occlusion of endotracheal tubes and nosocomial pneumonia. METHODS: A convenience sample of 24 critically ill patients were enrolled before having suctioning and after informed consent had been given. Ages ranged from 10 weeks to 14 years. Patients were randomized to 1 of 2 groups. In group 1, subjects received between 0.5 and 2.0 mL of isotonic sodium chloride solution, depending on their age, once per suctioning episode. In group 2, subjects received no such solution. A total of 104 suctioning episodes were analyzed. Oxygen saturation was recorded at predetermined intervals before and for 10 minutes after suctioning. Occlusion of endotracheal tubes and rates of nosocomial pneumonia also were compared. RESULTS: Patients who had isotonic sodium chloride solution instilled experienced significantly greater oxygen desaturation 1 and 2 minutes after suctioning than did patients who did not. No occlusions of endotracheal tubes and no cases of nosocomial pneumonia occurred in either group. CONCLUSIONS: Results of this study support a growing body of evidence that instillation of isotonic sodium chloride solution during endotracheal tube suctioning may not be beneficial and actually may be harmful.     

机械通气病人口腔护理溶液的研究进展

阐述机械通气病人口腔护理的作用，综述机械通气病人口腔护理溶液的研究进展，指出有效的口腔护理是降低呼吸机相关性肺炎发生率的重要措施之一，而口腔护理溶液的选择国内没有统一的规定，提出应通过循证护理证据等级和 Meta 分析的方法得到机械通气病人口腔护理溶液的统一指南。     

The ventilator care bundle and its impact on ventilator-associated pneumonia: a review of the evidence

Aims and objectives: The aim of this review was to critically analyse recent research that has investigated ventilator care bundle (VCB) use, with the objective of analysing its impact on ventilator‐associated pneumonia (VAP) outcomes. Background: The VCB is a group of four evidence‐based procedures, which when clustered together and implemented as an ‘all or nothing’ strategy, may result in substantial clinical outcome improvement. VAP is a nosocomial lung infection associated with endotracheal tube use in ventilated patients. Since the VCB was introduced there have been several studies that have reported significant VAP rate reductions. Search strategy: A comprehensive search for research, published between 2004 and 2009, was conducted using Medline and PubMed. Key words were used to identify English language studies reporting VCB implementation within adult intensive care units (ICU) and associated clinical outcomes. Studies that implemented bundle variations that did not include all four elements were excluded. Conclusions: Because of the limitations of the observational designs used in the studies retrieved, a definitive causal relationship between VCB use and VAP reduction cannot be stated. However, the evidence to date is strongly indicative of a positive association. Several studies reported the use of additional VCB elements. In these cases it is difficult to establish which elements are related to the measured outcomes. Further research is recommended to establish baseline outcome measures using the four‐element VCB, before adding further processes singly, as well as research investigating the effect of audit and feedback on VCB compliance and its effect on clinical outcomes. Relevance to clinical practice: A reduction in VAP is associated with VCB use. The evidence to date, whilst not at the highest experimental level, is at the highest ethically permissible level. In the absence of contradictory research, the current evidence suggests that use of the VCB represents best practice for all eligible adult ventilated patients in ICU.     

Complications associated with mechanical ventilation

A constellation of adverse effects and complications may be associated with mechanical ventilation, although in many instances the causal role of the ventilator itself has not been established. Complications occur with greater frequency than is generally appreciated, and tend to be under-reported in the medical literature. Among the potential adverse physiologic effects of positive-pressure ventilation are decreased cardiac output, unintended respiratory alkalosis, increased intracranial pressure, gastric distension, and impairment of hepatic and renal function. Failure of the ventilator to cycle, of safety alarms to function properly, and of inspired gas to be properly heated or humidified are examples of equipment-related complications. Perhaps most feared among medical complications occurring during mechanical ventilation are pneumothorax, bronchopleural fistula, and the development of nosocomial pneumonia; these entities may owe as much to the impairment of host defenses and normal tissue integrity as to the presence of the ventilator per se. Finally, a variety of avoidable "misadventures," due primarily to lapses of understanding and communication among the physicians, nurses, and respiratory care practitioners managing the ventilated patient, can adversely affect comfort, morbidity, and ultimate outcome.