COVID-19 has forced many severely ill patients to undergo mechanical ventilation for extended durations, an intervention that can increase their risks of other hospital-acquired infections such as ventilator-associated pneumonia (VAP).

By Yoona Ha


As COVID-19 continues to spread, hospitals are seeing more patients in the ICU that require prolonged ventilation. Studies have shown that around 250,000-plus patients get ventilator-associated pneumonia (VAP) each year in the US.1 Despite the lack of data on COVID-19 in the US is contributing to VAP rates, it’s safe to say that clinicians aren’t taking any chances. Any possibility of collective risk becoming collective reality can overwhelm our healthcare system, as seen in other parts of the world like Italy and Brazil. 

Across the world, cases of COVID-19 surpassed 15 million and respiratory providers are reporting VAP complications in COVID-19-hospitalized patients.2 As more patients require ventilation in ICU, more patients are staying in the hospital longer than 48 hours, which increases their risk of developing a hospital-acquired infection. It’s a vicious and costly cycle that can cost a healthcare facility anywhere from $19,325 to $80,013 per patient.3


From our experience covering VAP prevention strategies at RT, we’ve learned that managing VAP starts with common sense infection control practices that account for both indirect and direct routes of bacterial transmissions. But during the pandemic, there’s the added layer of complexity in spotting and treating VAP right away: both conditions share many of the same symptoms. So instead of using traditional diagnostic criteria, clinicians have to leverage pathogen identification trends from radiographic analysis, symptom development and lab findings that signal positive growth in culture of pleural fluid. 

So what should clinicians consider for preventing, identifying and treating VAP during and after the COVID-19 pandemic? We consulted with several experts to learn their take on best practices that healthcare decision makers in respiratory care can adopt.

Even Before the ICU, Lung Protective Measures Can Help

“It’s easy to portray VAP as an ‘ICU’ problem, but our experience shows us that the effects of poor positioning and incorrect tidal volumes can lead to negative outcomes for patients,” said Patrick Casey, MD, assistant medical director of Montgomery County Hospital District in the Greater Houston area. 

Casey pointed to a before-and-after study that looked to measure the effects of emergency department-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications. According to a multivariable logistic regression analysis of the study results of 1,705 patients total, suggested that lung protective mechanical interventions improved mortality and decreased ventilator duration in mechanically ventilated ICU patients.4

Since April 17, the Montgomery County Hospital District leveraged a prehospital lung protective ventilation bundle that encourages best practices like using head-of-bed positioning that decreases aspiration-related complications during the post-intubation period and titrating patients of oxygen down from 100% by calculating tidal volume based on height as opposed to weight. After starting these lung protective strategies, the hospital district reduced tidal volume by more than 20%, Casey confirmed.

“COVID-19 brought in an additional layer of complexity to managing patients that EMS providers are intubating—we know that some patients we intubate we’ll suspect that they’re COVID-19 patients,” Casey, a practicing emergency medicine physician, said.

Reduce the Time at Risk

What this changes, according to physicians like Casey, is not just how organizations are using PPE and other protective measures, but also how providers are approaching positioning, oxygenation and tidal volume choices to decrease ventilator use and overall mortality.

The World Health Organization’s guidance on reducing the instance of VAP in COVID-19 patients using ventilators proposes interventions such as: using oral intubation in adolescents and adult patients, keeping patients’ head-bed elevated at 30 to 45 degrees, closing and draining the suctioning system with condensate discarded in tubing, offering new ventilator circuits for each patient, changing those circuits if they become soiled or damaged and changing heat moisture exchanger every five to seven days or when its soiled or malfunctioned.5

Pathogenic microorganisms and the formation of biofilm on endotracheal tubes can also lead to VAP. Thus, focusing on prevention strategies that prevent secretions from pooling above the ETT cuff can be effective.6

A Simple Invention Tackles a Complex Problem

“The reality is that we spend a lot of time suctioning patients under anesthesia because they don’t quit producing spit,” said Nina Mclain, PhD, CRNA, associate professor and nurse anesthesia program coordinator at University of Southern Mississippi. “Every time you introduce a catheter to suction them, you’re creating micro trauma whether you want it or not.”

This concern for patients lead Mclain to wonder if there was a sponge-like device that she could put in the back of a patient’s throat that wouldn’t cause microtrauma. In 2013, there were other suction options that addressed this concern. Fast forward to today, Mclain said she is closer to introducing the device to the market. In 2018, she received US and international patents for the sponge-like tool. Generally, medical device FDA approval can up to several years, but Mclain said she hopes to introduce the device to market users for feedback soon.

Another option for patients is noninvasive ventilation, which does not require the use of artificial airways, is another option for clinicians to consider to prevent VAP altogether.

Getinge’s Neurally Adjusted Ventilatory Assist (NAVA) comes with diaphragm activity monitoring capabilities that allow for: monitoring and protecting the patient’s diaphragm activity, assess work and effort of breathing during weaning and prevent muscular exhaustion during weaning trials.

“Another key therapy to VAP reduction is the high-flow therapy, which can reduce the need for intubation and provide a bridge therapy after extubation, therefore, functioning to minimize a patient’s time on the ventilator,” said Bill Fralick, MBA, RRT, medical science liaison at Getinge. “Servo Compass is designed to help promote lung protective ventilation and provides clinicians to intervene earlier when a patient’s condition changes.”

New FDA-approved Pharmaceutical Options Emerge

Antibiotics are the frontline treatment option for VAP, but finding the right therapy for patients at risk for multidrug resistant (MDR) pathogens can be challenging. Thankfully, treatment options in the past few years have grown, which helps providers’ efforts to administer early and appropriate doses of antibiotics.

In 2019, the FDA approved Merck’s Zerbaxa for treatment of adults with VAP based on the results of phase 3 trial results that showed Zerbaxa’s efficacy in 726 adult patients on ventilators in hospitals. In June, the FDA also approved Merck’s Recarbrio, a drug generally used to treat complicated urinary tract infections, based on the results of a randomized, controlled clinical trial of 535 hospitalized adults with VAP. 

For ICU patients with MDR pathogens, treatment should involve “a strategy combining early high doses of effective agents with subsequent simplification in light of the microbiologic information.”7

What respiratory providers can all agree on is this: it’s better to prevent VAP than to have to treat VAP. These management strategies can be started even before the patient is admitted to the ICU.

So before COVID-19 overwhelms healthcare organizations, respiratory decision makers can play a critical role in preventing patients from preventable harm like VAP.


RT

Yoona Ha is a contributing writer to RT. For more information, contact [email protected].



Image: Klebsiella pneumoniae Bacteria. A human neutrophil interacting with Klebsiella pneumoniae (pink), a multidrug–resistant bacterium that causes severe hospital infections. Credit: National Institute of Allergy and Infectious Diseases, National Institutes of Health.



References

  1. Koenig S, Truwit J. Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clin Microbiol Rev. 2006 Oct; 19(4): 637–657. doi: 10.1128/CMR.00051-05.
  2. Chen N, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395:507–13. doi.org/10.1016/S0140-6736(20)30211-7.
  3. Agency for Healthcare Research and Quality. Estimating the additional hospital inpatient cost and mortality associated with selected hospital-acquired conditions. 2017. Accessed from https://www.ahrq.gov/hai/pfp/haccost2017-results.html https://www.ahrq.gov/hai/pfp/haccost2017-results.html.
  4. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A quasi-experimental, before-after trial. Ann Emerg Med. 2017. 70:3. Accessed via doi: 10.1016/j.annemergmed.2017.01.013.
  5. World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance. 2020. Accessed via www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. 
  6. Muscedere J, et al. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. Critical Care Medicine. 2011,39:8:1985-1991. Accessed from doi: 10.1097/CCM.0b013e318218a4d9
  7. Garnacho-Montero J, et al. How to treat VAP due to MDR pathogens in ICU patients. BMC Infect Dis. 2014. 14:135. Accessed from doi.org/10.1186/1471-2334-14-135.