Ventilator-associated pneumonia (VAP) is front of mind for any experienced critical-care staff member. It affects enormous swaths of ICU patients worldwide and can be deadly. It is also preventable in many cases. Hospital staff can learn from thousands of published case studies, clinical trials, and retrospective reviews. Each offers an insight into new ways to prevent, diagnose, and treat VAP. In many cases, small changes to VAP bundles and infection control protocols, including inside the bronchoscopy suite, can reduce VAP.
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There are also several emerging approaches to reducing VAP risk that include procedure and equipment alternatives. Hospitals can customize approaches to meet their unique needs, and ultimately, reduce VAP caused by bronchoscopy. Many hospitals have developed ways to circumvent challenges associated with reusable bronchoscopes to reduce VAP rates:
- Removing secretions from endotracheal tubes. Endotracheal tubes can contain stagnant secretions that contribute to biofilm formation. New devices that insert into endotracheal tubes can help wipe tubes clear of blockages and contamination. In one study, tubes treated with a wiping device every eight hours showed reduced mucus accumulation, and reduced colonization by VAP-causing bacteria. Devices that combine wiping with endotracheal tube suction may further help reduce bacterial colonization, but additional trials are needed to confirm this.
- Implementing single-use bronchoscopes. Single-use bronchoscopes eliminate challenges associated with reprocessing. Simplified instruments, single-use bronchoscopes provide basic functionality and may be easier to operate than their reusable counterparts. They require less prep time and may quicken procedures in the ICU. Their cost-effectiveness depends upon bronchoscopy load at a given hospital. Providers should consider reprocessing and repair costs associated with reusable bronchoscopes in cost-effectiveness calculations. More broadly, they must consider costs associated with cross-contamination and VAP. Single use bronchoscopes are not single patient. These scopes cannot be disinfected and stored for reuse in the same patient—even simply to check tube placement—without risk. They are designed for a single procedure. Single-use accessories should be handled similarly. Accessories such as disposable bronchoscope suction valves may also help minimize cross-contamination in the bronchoscopy suite.
- Reducing ventilator circuit cleaning. A perhaps counterintuitive innovation, studies have shown less is more when it comes to ventilator circuit cleaning. More frequent flushes do not affect VAP incidence. There is still a risk of circuit contamination from patient secretions, but this risk does not outweigh the risk of contamination associated with increased circuit handling and processing. Current guidelines from The Society for Healthcare Epidemiology of America indicate ventilator circuits should only be changed when they are visibly contaminated or malfunctioning.
- Minimizing antibiotic use. Antibiotic prophylaxis has also undergone an overhaul when it comes to mechanically-ventilated patients. “Antibiotics have fallen out of favor as a way to prevent VAP in a unit, due to fears that the drugs will progressively alter the host gastrointestinal flora and lead to superinfections with multidrug-resistant organisms,” note infection control specialists. These fears are appropriate, given the sheer volume of antibiotics now prescribed in ICUs. Approximately half of all antibiotics administered in ICUs are to treat VAP. Antibiotic treatment duration is also changing. One randomized trial of 401 VAP patients found no difference in mortality rates, or mechanical ventilation days, when comparing eight- and 15-day courses. Current guidelines align with these findings, and encourage providers to tailor antibiotic regimens to results of lower respiratory tract cultures, and shorten duration of therapy to the minimal effective therapy.
These innovations are encouraging. Overall, while VAP is a persistent challenge for hospitals, mortality associated with the complication are declining. New strategies are evolving to prevent colonization, aspiration, and infection in mechanically-ventilated patients. More data to support certain methods are certainly needed, but hospitals are already beginning to identify novel approaches that have true impact on VAP rates.