Care of the critically ill patient accounts for approximately 20% of hospital costs in the U.S., and approximately one third of these patients require mechanical ventilation (MV). Ventilator associated pneumonia (VAP) and agitation are frequent complications of mechanical ventilation. Nurses routinely and frequently move the endotracheal (ET) tube with the attached ventilator tubing, from side to side and up and down during care activities, procedures, and patient repositioning but the effect of this frequent ET tube movement on cuff leak, microaspiration and patient comfort is unknown. Since a major factor contributing to VAP is microaspiration around the ET tube cuff, the routine movement of the ET tube and attached ventilator tubing may have a significant effect on cuff leak, and therefore on VAP, warranting further investigation. Healthy People 2010 includes a goal to reduce the incidence of VAP in ICU patients by at least 10%. In an update of research priorities for nursing, the American Thoracic Society addresses an "emphasis on nursing interventions that decrease the incidence of ventilator-associated pneumonia." In addition, the 100,000 Lives Campaign to reduce ICU mortality by saving 100,000 lives, initiated by the Institute for Healthcare Improvement, had at its core, interventions to reduce VAP, such as the VAP bundle. Patients also experience anxiety and discomfort during mechanical ventilation from a variety of sources, but a primary cause of discomfort in these patients is the presence of the ET tube. This discomfort often leads to agitation and may be exacerbated by ET tube movement. Agitation has been shown to increase the length of stay in the hospital from a median of 5 days to 12 days. Reducing agitation and the use of sedation also reduces duration of MV and ICU length of stay, and therefore overall hospital costs. The movement of the ET tube may contribute to both microaspiration (which increases VAP risk) and agitation, increasing the need for sedative therapy. Both of these complications increase mortality and hospital costs. Therefore the primary aim of this study is to describe ET tube movement and its effect on ET tube cuff leak, agitation and patient comfort. A secondary aim is to describe the effect of nursing care on the amount, frequency, and type of ET tube movement. A sample of 50 subjects will be enrolled from surgical and medical intensive care units. ET tube movement, cuff pressure, and agitation will be continuously measured and the data downloaded in a bedside computer over a 4 hour data collection period. Patient comfort will be assessed every hour. Nursing activities will be documented using direct observation. Descriptive statistics and ANOVA will be used to determine the effect of ET tube movement on key variables.
|Hamilton, V Anne; Grap, Mary Jo (2012) The role of the endotracheal tube cuff in microaspiration. Heart Lung 41:167-72|