ED practices to prevent VAP

The Article:

Ventilator-Associated Pneumonia: The Potential Critical Role of Emergency Medicine In Prevention. Grap et al. The Journal of Emergency Medicine, Vol. 42, No. 3, pp. 353-362, 2012.

The Idea

To summarize the epidemiology, pathophysiology, and specific risk factors associated with ventilator associated pneumonia (VAP) and provide evidence based recommendations for its prevention.

Quick review:

VAP is thought to result primarily from the leakage of contaminated oropharyngeal secretions around the endotracheal cuff and into the lungs. Thus prevention efforts focus on variables that affect that process, including:

-oral health

-the endotracheal tube itself

-subglottic secretion accumulation

-backrest elevation

-gastric alkalinization

The paper reviews trials and meta-analyses that look at these variables.

The Findings/Recommendations:

1. Maintain backrest elevation at 30-45°

2. Apply chlorhexidine to the oral cavity immediately after intubation and q 12 hrs thereafter

3. Ensure ETT security to reduce unplanned extubations and subsequent reintubations

4. Measure ETT cuff pressures (goal 20-30 cm H2O) immediately after intubation and q 4 hrs

5. Consider use of continuous subglottic secretion drainage for patients likely requiring 48 hrs or more of mechanical ventilation

The Takeaway:

Given the large number of patients intubated in the ED and the increasing length of stay in the ED before being transferred to the ICU, implementation of practices that can decrease the incidence of VAP should start in the ED. Easy to implement actions include maintaining backrest elevation at 45°, applying chlorhexidine to the oral cavity immediately following intubation, and securing your ETT tube to avoid reintubation.