Melody Bennett

Evaluation of an Intervention to Maintain Endotracheal Tube Cuff Pressure Within Therapeutic Range

BACKGROUND Endotracheal tube cuff pressure must be kept within an optimal range that ensures ventilation and prevents aspiration while maintaining tracheal perfusion. OBJECTIVES To test the effect of an intervention (adding or removing air) on the proportion of time that cuff pressure was between 20 and 30 cm H(2)O and to evaluate changes in cuff pressure over time. METHODS A repeated-measure crossover design was used to study 32 orally intubated patients receiving mechanical ventilation for two 12-hour shifts (randomized control and intervention conditions). Continuous cuff pressure monitoring was initiated, and the pressure was adjusted to a minimum of 22 cm H(2)O. Caregivers were blinded to cuff pressure data, and usual care was provided during the control condition. During the intervention condition, cuff pressure alarm or clinical triggers guided the intervention. RESULTS Most patients were men (mean age, 61.6 years). During the control condition, 51.7% of cuff pressure values were out of range compared with 11.1% during the intervention condition (P < .001). During the intervention, a mean of 8 adjustments were required, mostly to add air to the endotracheal tube cuff (mean 0.28 [SD, 0.13] mL). During the control condition, cuff pressure decreased over time (P < .001). CONCLUSIONS The intervention was effective in maintaining cuff pressure within an optimal range, and cuff pressure decreased over time without intervention. The effect of the intervention on outcomes such as ventilator-associated pneumonia and tracheal damage requires further study.

Oropharyngeal Secretion Volume in Intubated Patients: The Importance of Oral Suctioning

BACKGROUND Aspiration of secretions that accumulate above the cuff of the endotracheal tube is a risk factor for ventilator-associated pneumonia. Routine suctioning of oropharyngeal secretions may reduce this risk; the recommended frequency for suctioning is unknown. OBJECTIVES To quantify the volume of secretions suctioned from the oropharynx of critically ill patients at 2 different intervals to assist in identifying a recommended frequency for oropharyngeal suctioning. METHODS A prospective, repeated measure, single-group design was used. Twenty-eight patients who were orally intubated and treated with mechanical ventilation were enrolled; 2 were extubated during data collection, yielding a sample of 26 patients. The patients were suctioned at baseline with a deep suction catheter, and the volume and weight of secretions were recorded. The procedure was repeated at 2-hour and 4-hour intervals. RESULTS Most of the patients were male (mean age, 49 years). Three suctioning passes were needed to clear secretions, with a mean time of 48.1 seconds. The mean volume of secretions at the 2-hour interval was 7.5 mL. Five patients required suctioning before the 4-hour interval. For the remaining 21 patients, the volume retrieved was 6.5 mL at the 2-hour interval and 7.5 mL at the 4-hour interval (P = .27). The 5 patients who required extra suctioning had significantly more secretions at the 2-hour interval (11.6 mL vs 6.5 mL; P = .05). CONCLUSIONS A minimum frequency of oropharyngeal suctioning every 4 hours is recommended. However, more frequent suctioning may be needed in a subset of patients.

Clinical Indicators for Endotracheal Suctioning in Adult Patients Receiving Mechanical Ventilation

BACKGROUND Critically ill patients who need mechanical ventilation require endotracheal suctioning. Guidelines recommend coarse crackles over the trachea and/or the presence of a sawtooth pattern on the flow-volume loop of the ventilator waveform as the best indicators. OBJECTIVE To determine clinical cues for endotracheal suctioning in patients who require mechanical ventilation. METHODS A descriptive study of 42 adult patients receiving mechanical ventilation. After baseline endotracheal suctioning with a closed-system device, patients were assessed hourly up to 4 hours for guideline-based cues for endotracheal suctioning and lung sounds were auscultated. Endotracheal suctioning was done when cues were detected or 4 hours after baseline suctioning. Secretions were collected, measured, and weighed. RESULTS Most patients were male (62%) and white (93%). Mean age was 51 years, and mean duration of mechanical ventilation was 7.5 days. The median time to endotracheal suctioning was 2 hours, and a mean of 4.4 mL of secretions was removed. Three patients had no cues identified but had 1.0 mL or more of secretions. The most frequent cues were crackles over the trachea (88%), sawtooth waveform (33%), coughing (29%), and visible secretions (5%). Cues resolved and physiological parameters improved after suctioning. Coarse lung sounds did not improve. CONCLUSIONS Patients receiving mechanical ventilation should be routinely assessed for coarse crackles over the trachea, the most common indicator for endotracheal suctioning. Despite common practice, assessment of lung sounds to identify the need for suctioning is not supported.

Comparison of Airway Management Practices Between Registered Nurses and Respiratory Care Practitioners

BACKGROUND Airway management, an essential component of care for patients receiving mechanical ventilation, is multifaceted and includes oral hygiene and suctioning, endotracheal suctioning, and care of endotracheal tubes. Registered nurses and respiratory care personnel often share responsibilities for airway management. Knowledge of current practices can help facilitate evidence-based practices to optimize care of patients receiving mechanical ventilation. OBJECTIVES To describe current practices for airway management of intubated patients and determine if practices differ between registered nurses and respiratory care practitioners. METHODS A descriptive, comparative design was used. Registered nurses and respiratory care practitioners who provided direct care to intubated patients receiving mechanical ventilation were recruited to complete an online survey of self-reported practices. RESULTS A total of 85 participants completed the survey. Most were experienced caregivers with a bachelors degree and certification or registration in their field. Selected practices have improved, including increasing oxygen saturation before endotracheal suctioning, maintaining pressure of endotracheal tube cuffs, and providing oral hygiene and suctioning. The practices of registered nurses and respiratory care practitioners differed in many ways. The nurses assumed responsibility for oral antisepsis, whereas the respiratory care practitioners managed the endotracheal tube. The 2 groups shared responsibility for oral and endotracheal suctioning. Knowledge of current guidelines for endotracheal suctioning was lacking. CONCLUSIONS Practices in airway management have improved, but opportunities exist to develop shared policies and procedures based on current evidence.

Comparison of Respiratory Infections before and after Percutaneous Tracheostomy

BACKGROUND A tracheostomy is often performed when patients cannot be weaned from mechanical ventilation. Respiratory infections (ventilator-associated pneumonia and infection of the lower respiratory tract) complicate the course of hospitalization in patients receiving mechanical ventilation. OBJECTIVES To evaluate respiratory infections before and after a percutaneous tracheostomy and to describe their outcomes. METHODS Medical records of adults who had percutaneous tracheostomy during a 1-year period at a tertiary care hospital in the southeastern United States were reviewed retrospectively. RESULTS Data for 322 patients were analyzed. Patients were predominately male (63.0%) and white (57.8%), with a mean age of 57.4 years. Ventilator-associated pneumonia or infection of the lower respiratory tract was identified in 90 patients (28.0%); the majority of infections were lower respiratory infections. Of all infections, 52% occurred before the tracheostomy, and 48% occurred after the procedure. Respiratory infections were associated with longer stays and higher costs, which were significantly higher in patients in whom the infection developed after the tracheostomy. Gram-negative organisms were responsible for the majority of infections. CONCLUSIONS Data related to respiratory infections that occurred before a tracheostomy were similar to data related to infections that occurred after a tracheostomy. Most infections were classified as lower respiratory infection rather than pneumonia. Infection, before or after a tracheostomy, resulted in longer stays and higher costs for care. Interventions focused on preventing infection before and after tracheostomy are warranted.

1090: ASSOCIATION BETWEEN INTUBATION FACTORS AND ASPIRATION AND VENTILATOR-ASSOCIATED CONDITIONS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Tracheal intubation in the prehospital setting has been associated with increased risk for aspiration. Using data from an ongoing study, we evaluated tracheal intubation variables with tracheal amylase and pepsin A (aspiration), and ventilatorassociated conditions (VAC). We hypothesized that subjects intubated in the field would have higher rates of aspiration and VAC. Methods: Intubation and outcome data were collected as part of an ongoing oral suction trial in ventilated patients. Consent was obtained from patient or legal proxy. Adult subjects (≥ 18) were enrolled within 24 hours of oral intubation and followed while intubated, up to 14 days. Documented aspiration at time of intubation was an exclusion criterion. Primary outcomes were tracheal amylase and VAC (NHSN criteria). Tracheal pepsin A values were evaluated in a subset (n = 84). Data were analyzed with chi-square and ANOVA. Results: Data were analyzed from 368 subjects: mean age 57.7 (18.7) years, 56.3% male, 74.2% white, 19.3% Hispanic. Intubation location was study site (82.9%), other hospital (9.2%), and field (7.9%). The ICU (39.9%) and ED (37.8%) were the most common units. Most patients (76.4%) had a positive amylase (≥ 396 IU/L) while 16.7% had a positive pepsin A (≥ 6 ng/mL) in baseline tracheal specimens. Although not significant, mean tracheal amylase values were highest for field intubations (p = 0.64); mean tracheal pepsin A values were highest for intubations at the study site (p = .61) and if more than one intubation attempt was required (p = .11). VAC rates were significantly higher for other hospital intubations (29.4%) compared with study site (11.1%) or field (10.3%, p = 0.009), and for those that required more than one intubation attempt (21.3% vs 10.0%; p = .02). Conclusions: Aspiration of oral and gastric contents was observed despite exclusion criterion of no documented aspiration during intubation. Strategies to ensure successful intubation with one attempt are needed. Further research is warranted to identify clinical implications of aspiration and explore VAC rates associated with interhospital transfers. (1R01NR014508)

Collecting Nursing Research Data 24 Hours a Day: Challenges, Lessons, and Recommendations

Background Research on many routine nursing interventions requires data collection around the clock each day (24/7). Strategies for implementing and coordinating a study 24/7 are not discussed in the literature, and best practices are needed. Objective To identify strategies incorporated into implementing a nursing intervention trial 24/7, including key lessons learned. Methods Strategies to facilitate implementation of a clinical trial of a nursing intervention with patients undergoing mechanical ventilation are shared. Challenges and changes for future studies also are discussed. Results Adequate planning, including a detailed operations manual, guides study implementation. Staffing is the most challenging and costly part of a study but is essential to a study’s success. Other important strategies include communication among the study personnel and with collaborators and direct care staff. An electronic method of recording study‐related data also is essential. Conclusions A nursing clinical trial that requires interventions on a 24/7 basis can be done with thorough planning, staffing, and continuous quality improvement activities.

Characteristics, resource utilization, and nursing care of patients who undergo percutaneous tracheostomy.

Purpose/Objectives: Many critically ill patients require a tracheostomy when unable to be weaned from prolonged ventilator support. This study describes the characteristics, resource use, and outcomes of patients who required a tracheostomy for failure to wean from mechanical ventilation. Design: A retrospective descriptive study was conducted to analyze data from the electronic medical record and hospital databases. Setting: The setting was a tertiary care hospital with a level I trauma center. Sample: Data from 363 adult subjects who underwent a tracheostomy after prolonged mechanical ventilation during a 1-year period were obtained from hospital databases. All underwent a percutaneous procedure. The majority of subjects were male (62.8%) and white (57.9%), with a median age of 59 years. Nearly half had a trauma diagnosis. Results: Hospital mortality was low (9.9%). Ventilator days, hospital/intensive care unit lengths of stay, and costs were high. Only 7.1% of subjects were discharged directly from the hospital to home. Others were transferred to long-term acute-care hospitals, rehabilitation centers, skilled nursing facilities, and other hospitals. Those who had the tracheostomy done prior to 10 days of ventilation had better outcomes; however, these same subjects had lower acuity scores. Within 1 day of the procedure, ventilator settings were reduced, airway pressures were lower, and level of sedation was improved. Conclusions: Patients requiring a tracheostomy incur high resource use, and although the majority was transferred to other facilities, the number discharged directly home was low. Improved physiological parameters and reduced ventilator settings following the tracheostomy facilitated weaning from ventilation. Implications: Knowledge of characteristics and outcomes may assist in identifying interventions to reduce the need for tracheostomy or improve outcomes. In particular, the clinical nurse specialist can lead team initiatives to promote weaning prior rather than performing a tracheostomy as well as interventions postprocedure to improve discharge outcomes.