I have a few questions about the VAP Bundle and trach tubes

Altra, BSN, RN · Oct 5, 2010

I believe you are speaking of 3 common protocols for hospitalized patients, particularly critical patients:

1) VAP = ventilator-associated pneumonia

2) PPI use/peptic ulcer prophylaxis

3) DVT prophylaxis

Critically ill, immobile patients are at risk for all of these (or at least #2 & #3, if not on a vent).

VAP prophylaxis typically includes keeping the HOB inclined at least 30 degrees, use of an oral chlorhexidine solution for swabbing the oral cavity, and encouraging coughing/deep breathing.

Stress/peptic ulcer prophylaxis includes daily PPI administration.

Risk of DVTs related to immobility and/or other circulatory compromise can be mitigated by use of SCDs or other compression hosiery and/or daily SQ Heparin.

These 3 protocols each address a risk of a different side effect of critical illness and immobility. The maintenance of skin integrity is another important protocol for critically ill, immobile patients.

In my experience, if after 2-3 weeks of intubation the patient still cannot be weaned off the vent and requires an artificial airway then it's time for a tracheotomy.

I'm not sure of your background -- hope this helps to answer your questions.

NuteRN · Oct 5, 2010

[color=#0e774a]try looking through this power point. it might answer some of your questions.

[color=#0e774a]

[color=#0e774a]www.flpic.com/vap_prevention_cjl_10-08.ppt[color=#767676]

GreyGull · Oct 5, 2010

The ETT is inserted into the mouth, then down the trach and a balloon hold it in place?

The balloon or cuff is never meant to "hold" the ETT or trach in place. If that is the intent or misunderstood purpose of the person inflating the cuff, they will probably over inflate it to where there will be damage to the tracheal wall in just a few hours. The RTs will do an MLT (Minimal Leak Technique) also known as MOP (Minimal Occluding Pressure) or they will measure the pressure in the cuff with a manometer with the ideal range of 18 - 22 cm H2O. The purpose is to have the cuff inflated just to a point where it prevents a leak during mechanical ventilation.

So also believe the cuff prevents aspiration. This is not totally true. Since the cuff is located below the cords, it only slows the inevitable. Hospitals that are serious about their VAP rates invest in ETTs and trachs with supraglottic suction ports located just above the cuff. These ports are connected to continuous wall suction (-20 cmH2O) to help remove oral secretions before they get past the cuff. In the past it was also thought that you had to inflate the cuff for a patient to eat. It was later found that this increased the risk of aspiration by interfering with the ablility to equalize the tracheal and esophageal pressures for effective swallowing. Now the cuff is deflated and a speaking valve (PMV or Passy Muir) is placed.

How long do patients typically keep this in for?

A tracheotomy is a procedure performed in surgery for long-term trach patients?

A patient is intubated with an ETT for as long as they need the ventilator. If the ventilator will be required for a long time or they are a difficult wean, a tracheotomy is done and a trach will be placed. The time frame for placing a trach in a patient depends on the reason the patient is on the ventilator.

If the patient has paralysis from an injury such as that to the C-spine, the patient may be trached the same day of the injury while they are in surgery for spinal stabilization.

If it is a neuro cause such as a CVA or TBI, the patient will be assessed for their ability to maintain secretions and their airway gag reflex. If there is an impairment, the patient may be trached within 7 - 10 days.

For ARDS, COPD or some other condition, they may wait 2 - 3 weeks to give the patient a chance to resolve the cause.

Some tracheotomys are done in the ICU at the beside.

Many patients are decannulated not too long after they are weaned from the ventilator or when they get stronger from their initial condition. Even some quadriplegics can be decannulated if they are no longer ventilator dependent. It will depend on the effectiveness of their cough and secretion clearance.

However, some patients will have a trach permanently. Christopher Reeve (Superman) had his trach and ventilator for 8 years. His trach was probably placed soon after his accident.

Liz Taylor had an emergent tracheotomy done with a trach for a short time until she got stronger after a bad PNA.

The stomas of tracheotomy patients will start to close within a few minutes or a few hours if the trach is removed. This further facilitates the weaning process when it is determined the patient no longer needs the trach.

Some patients need to have a permanent opening and will have a tracheostomy formed with the trachea forming the stoma. There is no longer a communication with the upper airway. This is common for larygectomies, oral, pharyngeal or esophageal CAs which may require a radical neck surgical procedure.

sunnycalifRN · Oct 5, 2010

GreyGull, very nice explanation. There's nothing to add.

nurse2033, MSN, RN · Oct 5, 2010

Just one more thing, ET tubes can only be used for about 10 days. The thin tissue lining the trachea can be injured or infarcted by the cuff, even if cuff pressures are not high. As you can imagine a tracheal erosion is a bad thing. If the patient looks like they will continue to need the vent tracheostomy is done at that time.

GreyGull · Oct 5, 2010

Just one more thing, ET tubes can only be used for about 10 days. The thin tissue lining the trachea can be injured or infarcted by the cuff, even if cuff pressures are not high. As you can imagine a tracheal erosion is a bad thing. If the patient looks like they will continue to need the vent tracheostomy is done at that time.

Getting the patient trached by the 10th day is ideal for some situations but not set in stone. The main reasons we trach is to facilitate ventilator weaning and moving the patient out of ICU to a step down or a subacute quicker.

Actually with the ETTs that have been developed over the past 10 - 15 years, an ETT can stay in longer than 10 days easily if cuff pressure is monitored and you have a proper humidification system to keep the tubes from plugging. Monitoring skin intergrity and rotating the tube's lip position with daily face care are also essential.

The humidification can now be a challenge with all the hypothermia protocols for neuro and cardiac arrest patients where the heated wired/water systems are turned off and the body temp affects the HMEs.

Last H1N1 flu season we did have patients go easily for 3 - 4 weeks since they were on HFOVs and then conventional ventilators for a long time. The longest HFOV patient was 15 days and there was not much chance of traching that patient or having a fresh trach on that machine easily.

Also, patients who require mechanical ventilation such as in subacutes may require their trach cuff inflated to MOP or the appropriate cuff pressure indefinitely or the rest of their lives which could be several years.

However, we will change out the tubes used in the field because they are usuallly cheap and can cause damage more readily even with careful monitoring. We also know they were inserted in a less than idea situation. And, we like using our subglottic suction tubes if the patient is intubated for more than 48 hours or will be getting a paralytic.

I suppose the 10 day rule could also be required if the hospital is using the same cheaper tubes as EMS. We have rec'd a few patients from other hospitals that were noticed to have the "not so great" tubes in place. Those got changed once the patient was stable enough in the ICU.

Of course, here are also some Critical Care physicians and surgeons who believe firmly in the 10 day rule which was very prevalent 20+ years ago.

Altra, BSN, RN · Oct 5, 2010

I agree Grey Gull -- in my ICU 2-3 weeks is common before a trach is performed. Every effort is made to wean them from the vent in that time, but we still see a lot of trachs.