Ventilator-associated pneumonia (VAP) is a common nosocomial pneumonia that occurs in critically ill patients and results in mortality rates as high as 71%. Subglottic secretions (SSs) are a known risk factor. Several clinical trials have shown that continuous aspiration of subglottic secretions (CASS) reduces the risk of VAP by nearly half. Optimal suction pressure levels needed to efficiently evacuate viscous SSs are unknown. The purpose of this study was to describe SSs and the effective suction pressure (20 mmHg, 30 mmHg, 40 mmHg, and 50 mmHg) needed to maximize evacuation efficiency based on SS volume (2 ml, 4 ml, and 6 ml) and viscosity (watery, thick, and gel-like). A laboratory model was designed to replicate a human trachea. Thick secretions had the highest percentage of mean recovery representative of evacuation efficiency of SSs (mean recovery of 86%). The suction pressure of 30 mmHg had the highest overall mean of secretion recovery (83%) across all viscosity types and amounts. This study demonstrated that higher viscosity secretions were easier to evacuate than lower viscosity secretions when 30-mmHg suction pressure was applied. Management of secretion viscosity may assist in secretion removal and delay VAP development. With increased understanding of the molecular structure of SSs, there is the potential that clinicians will be able to manipulate secretion viscoelastic properties to maximize evacuation efficiency of the secretions. Further research is needed to identify safe suction pressures for optimal evacuation of SSs in human subjects.
Abstract:The purpose of this study was to compare the level of dyspnoea with and without the use of 5-cc saline instillation prior to endotracheal suctioning of mechanically ventilated adults. A crossover, quasi-experimental design was used. Seventeen alert, mechanically ventilated adults were asked to rank their level of dyspnoea using the vertical visual analogue scale at specific time intervals surrounding two suctioning events. Saline was randomly assigned to be instilled prior to one of two suctioning episodes. Dyspnoea was ranked immediately after suctioning, and at 10-, 20-, and 30-minute intervals. Data were analyzed using repeated measures analysis of variance with time of measure (immediately after suctioning, 10-, 20-, and 30-minute intervals) and treatment type (with saline versus without saline instillation). The level of dyspnoea based on treatment type (with or without saline) was non-significant. Treatment type by age group interaction was significant (F(1, 15) = 5.41, P = 0.034). The nature of the interaction revealed that older patients (<60 years of age) experienced less dyspnoea without saline prior to suctioning and greater dyspnoea with saline instillation as compared to the younger subjects (<60 years of age). This study documented no beneficial effects of saline. However, it did demonstrate that saline instillation might precipitate a significantly increased level of dyspnoea for up to 10 minutes after suctioning in patients older than 60 years of age. Recommendations based on the results of this study would be to avoid the use of saline instillation prior to suctioning. Article:Patients who are intubated require suctioning. Because having an endotracheal tube (ETT) inserted through the mouth to the trachea interrupts the first-line defence mechanism, one is unable to naturally remove foreign debris or intrinsic mucus by coughing. In order to facilitate secretion removal, endotracheal suctioning (ETS) is performed. There is controversy in clinical practice as to whether to perform ETS with or without saline instillation prior to suctioning. Many research studies have analysed the effect of saline instillation prior to suctioning on secretion removal, oxygen saturation, dislodgment of bacteria, physiologic variables and other factors (Ackerman et
The current project assessed the oral health of residents in a long-term care (LTC) facility, implemented a new evidence-based oral care protocol, and trained nursing staff about oral hygiene for older adults. A pre-/post-intervention design was used to measure knowledge, skills, and attitudes among 29 staff members. The oral health outcomes of 10 LTC residents without dysphagia were assessed after 14 days of protocol use. Knowledge improved from a mean total pre-test score of 88.8 to a mean total post-test score of 97.7 ( Z = −2.308, p = 0.021). The Oral Health Assessment Tool measured oral health outcomes at three time points in 10 older adults, and statistically significant improvement in oral health was identified ( p = 0.001). Nursing home staff play an important role in improving oral hygiene of older adults in LTC facilities by routinely using an easy to follow oral health protocol twice daily. [ Journal of Gerontological Nursing, 46 (5), 33–39.]
Ventilator-associated pneumonia (VAP), a specific type of nosocomial pneumonia, occurs in approximately 21% of patients in intensive care, and the mortality can be as high as 71%. VAP causes considerable mortality and morbidity, and it exponentially increases health care costs. The incidence of VAP is associated with oropharyngeal colonization of gram-negative bacteria. Within 48 h of hospital admission, the composition of the oropharyngeal flora of critically ill patients undergoes a change from the usual gram-positive streptococci and dental pathogens to a predominant gram-negative flora that includes more virulent organisms, which predispose patients to VAP. Identification and understanding of this oral transition from gram-positive to predominantly gram-negative flora may assist health care professionals in differentiating among oral immune markers that suggest compromised immunity. The purpose of this article is to provide a review of the literature that promotes an understanding of current knowledge about the transition of oral immunity in mechanically ventilated patients.
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