Fight ventilator associated pneumonia with noninvasive ventilation

Being a healthcare provider can be a rewarding career, but it is never without risks or consequences. Not only do you need to worry about treating patients for their immediate condition, but you must also do so knowing what risks or potential harm you may be exposing them. This is particularly true in care areas like ICUs, which tend to inherit the clinical consequences and financial implications of decisions made in other units—emergency departments, for example.

A common scenario is when a COPD exacerbation, CHF, and/or respiratory insufficiency patient presents at the ED.  In many instances, when this type of patient arrives in the emergency room, the physician's immediate reaction is to intubate.  But is that really the right choice?  It's important to remember that patients who have been intubated for more than 48 hours are prime candidates for VAP (ventilator-acquired pneumonia).  VAP is one of the most significant hospital acquired infection (HAI) risks facing intubated patients on a ventilator.¹ According to the Centers for Medicare and Medicaid Services, the average cost of a VAP infection runs about $135,795 per hospital stay with an estimated 30,867 reported cases of VAP in the US each year.²   CMS was urged to add VAP to its list of conditions for which there would be no additional payment above the base DRG for 2008. A majority of commenters believe this condition can be reasonably prevented through evidence-based medicine guidelines.³ Clinical evidence seems to support their contention.  Hospital mortality of ventilated patients who develop VAP is 46% compared to 32% for ventilated patients who do not develop VAP.⁴   So, if you were able to help prevent a patient from being intubated while assisting them with their ventilation, wouldn't that serve a greater purpose?  There is in fact a clinically proven way to improve patient outcomes, save the hospital the costs associated with intubation- such as length of stay, equipment, supplies-and help prevent VAP.  It's called noninvasive ventilation (NIV). 

According to Dr. Dean Hess, the ventilator is not the problem, it's the endotracheal tube that's the real culprit.⁵ When a patient is in need of ventilation for respiratory insufficiency, why not fight the initial urge to intubate and consider noninvasive ventilation?  The CDC 2004 Guidelines for Preventing Health-Care Associated Pneumonia (VAP) states, "When feasible and not medically contraindicated, use noninvasive positive-pressure ventilation delivered continuously by face or nose mask, instead of performing endotracheal intubation in patients who are in respiratory failure and are not needing immediate intubation."⁵ In fact, NIV has been shown to reduce the rate of VAP compared to ETI to such an extent that some experts have called for the name be changed from "Ventilator Associated Pneumonia" to "Intubation Associated Pneumonia."

The good news is that VAP prevention can start even before the patient arrives in the hospital.  Both ALS and BLS emergency providers are now authorized to use continuous positive airway pressure (CPAP) - a basic form of noninvasive ventilation via a face mask - in most states.  There is strong evidence supporting the application of NIV in patients with congestive heart failure and chronic obstructive pulmonary disease (COPD) exacerbation, and for immunocomprised patients and COPD patients being weaned from mechanical ventilation. There is also moderately strong evidence to support NIV in patients with asthma, cystic fibrosis, postoperative respiratory failure, and DNI (do not intubate) requests.  While NIV offers significant cost advantages over traditional ventilation via endotracheal intubation, it also offers equally significant benefits to patients in the form of decreased length of stay (LOS), reduced sedation that is associated with intubation and decreased morbidity and mortality rates.¹  Unfortunately, once these patients have been intubated, NIV is really only an option during the weaning phase.  Furthermore, NIV preserves the patient's ability to communicate with clinicians and loved ones, an important consideration for their psychological and emotional wellbeing.

So what are some of the main considerations for noninvasive ventilation?  There are basically three major things to consider for NIV success:  1) using a dedicated NIV ventilator; 2) applying and fitting the right interface; 3) undergoing effective training.

Dedicated NIV ventilator. The dedicated NIV ventilator is important to reach the necessary pressures and flows to satisfy the patient's ventilatory needs.  It provides optimal patient-to-ventilatory synchrony and is best suited for managing dynamic leaks or compensating for patient movements, which can cause sudden variability in unintentional mask leaks. 

Interfaces.  If the patient isn't comfortable with the therapy, he or she will not be cooperative and the therapy will inevitably fail.  Just as an ETT is critical to the intubated patient, the interface is critical to NIV success.  Having a choice of multiple interfaces (total face, oro-nasal, or nasal) in different sizes assists the clinician in making the right choice for the individual patient.  Recent interface innovations have created a wide range of comfortable mask solutions suited for almost any face-type and patient preferences.

Clinician training.  Dr. Nicholas Hill, a prominent expert on noninvasive ventilation, stated in a 2006 Chest article, "The utilization rates of noninvasive positive-pressure ventilation vary among different acute care hospitals within the same region.   The perceived reasons for lower utilization rates (of NIV) include lack of physician knowledge, insufficient respiratory therapy training and inadequate equipment."⁶   Understanding the role and importance of proper training is a significant step towards effective utilization and successful implementation of an NIV program.

First responders and emergency room physicians need to be aware of the risks and consequences that accompany their decision to intubate patients in respiratory distress.  Research continues to show that VAP is closely associated with intubation and that such HAIs come with a high cost for both patient and hospital.  Although clearly not indicated for every patient, NIV represents a viable alternative to intubation for a significant subset of patients in respiratory distress.  For these patients, the decision to ventilate noninvasively may well save them from the costly and potentially deadly consequences of VAP.  You could say that NIV helps both patients and clinicians breathe a little easier.

References:

¹Nelson-Artibey, P., The Cost Effectiveness of Noninvasive Ventilation (NIV) in Hospital and Pre-Hospital Settings; Respiratory Therapy June-July 2010; Vol 5, No 3; 30-1.

²CMS Proposes Additions to List of Hospital-Acquired Conditions for Fiscal Year 2009. http://www.cms.hhs.gov/apps/media/press/fastsheet/asp?

³Medicare IPPS 2008

⁴Mather, J. Pulmonary Associates of Richmond, ppt presentation for Chest; 2008

 CDC MMWR Mar 2004;53:RR-3

⁵Hess, D. Noninvasive Positive-Pressure Ventilation and Ventilator-Associated Pneumonia, Resp Care 2005;50(7):924-929

⁶ Hill, N. Utilization of Noninvasive Ventilation in Acute Care Hospitals: A Regional Study; Chest 2006;129:1226-1233)