Working for the silent

What do you believe is the most effective way to prevent ventilator-associated pneumonia?

VAP is merely the tip of the iceberg when it comes to the $11 billion problem of post-operative pulmonary complications. However, the single most effective way to reduce the risk of VAP is to get patients off mechanical ventilation as soon as possible. Though much of this is patient dependent, there are technologies that have been demonstrated to help. One method is the use of specific modes of ventilation, such as Proportional Assist Ventilation™ Plus, (known as PAV™+), which works to reduce the amount of work a patient needs to breathe and reduce weaning time. However, when mechanical ventilation is unavoidable, a second data-driven method is the Mallinckrodt™ Evac technology, which works to reduce microaspiration of subglottic secretions past the endotracheal tube cuff.

What is your opinion of the strategy of removing secretions from above the endotracheal cuff?

ICU literature has recognized the role of subglottic secretions in the pathogenesis of VAP for more than a decade. These secretions collect below the cords and above the cuff, making them a challenge to remove with typical suctioning methods. The integrated suction lumen, however, allows direct access to this region for easy evacuation. Multiple randomized controlled trials have demonstrated a reduction in VAP using Mallinckrodt™ Evac technology.

Are there any technological innovations in endotracheal cuff design that could reduce the risk of microaspiration?

Conventional endotracheal cuffs do not offer a perfect barrier to microaspiration. To ensure contact with the trachea at low pressures when inflated, cuffs are designed to have an expanded diameter greater than the diameter of the trachea. The result of this design, when inflated in the trachea, is excess cuff material that invaginates, creating longitudinal channels that allow the propagation of material from above the cuff down into the distal respiratory tract. An innovative solution is to change the shape of the cuff to a fully tapered design, which is found on the Mallinckrodt™ TaperGuard™ and SealGuard™ endotracheal tube lines. This ensures that at some point in the expanded cuff, the cuff diameter will approximate the tracheal diameter and channels will be reduced. Multiple studies have demonstrated decreased leakage with these two new endotracheal tube cuffs.

In your view, what do we (hospitals, healthcare organizations) need to do in order to achieve a dramatic reduction in the incidence of post-intubation pulmonary complications?

The most studied post-intubation pulmonary complication is VAP, though there are likely many others. Hospitals should consider using strategies that work to fight the mechanism of action of these complications, such as the microaspiration of subglottic secretions.

What should a healthcare organization look for when choosing a supplier of mechanical ventilation and respiratory care devices?

Healthcare organizations should consider partnering with a supplier that has a long track record of focusing on the clinician’s needs, as well as on both clinical and economic value. It is not enough to provide devices that improve outcomes; they must do so cost-effectively. Covidien is committed to developing products that provide clinical value as well as help reduce healthcare costs and length of stay.

BIO:

Douglas Hansell, M.D., M.P.H., is Vice President and Chief Medical Officer for Covidien Respiratory and Monitoring Solutions. A Harvard-based physician, Dr. Hansell has more than 20 years of multi-sector healthcare experience. In addition, Hansell has maintained an active clinical practice in anesthesiology at Massachusetts General Hospital in Boston and has held teaching appointments at Harvard University. Hansell is board certified in Internal Medicine and anesthesiology, fellowship trained in cardiovascular anesthesia and experienced in critical care medicine.

What do you believe is the most effective way to prevent ventilator-associated pneumonia?

VAP is merely the tip of the iceberg when it comes to the $11 billion problem of post-operative pulmonary complications. However, the single most effective way to reduce the risk of VAP is to get patients off mechanical ventilation as soon as possible. Though much of this is patient dependent, there are technologies that have been demonstrated to help. One method is the use of specific modes of ventilation, such as Proportional Assist Ventilation^TM Plus, (known as PAV^TM+), which works to reduce the amount of work a patient needs to breathe and reduce weaning time. However, when mechanical ventilation is unavoidable, a second data-driven method is the Mallinckrodt^TM Evac technology, which works to reduce microaspiration of subglottic secretions past the endotracheal tube cuff.

What is your opinion of the strategy of removing secretions from above the endotracheal cuff?

ICU literature has recognized the role of subglottic secretions in the pathogenesis of VAP for more than a decade. These secretions collect below the cords and above the cuff, making them a challenge to remove with typical suctioning methods. The integrated suction lumen, however, allows direct access to this region for easy evacuation. Multiple randomized controlled trials have demonstrated a reduction in VAP using Mallinckrodt^TM Evac technology.

Are there any technological innovations in endotracheal cuff design that could reduce the risk of microaspiration?

Conventional endotracheal cuffs do not offer a perfect barrier to microaspiration. To ensure contact with the trachea at low pressures when inflated, cuffs are designed to have an expanded diameter greater than the diameter of the trachea. The result of this design, when inflated in the trachea, is excess cuff material that invaginates, creating longitudinal channels that allow the propagation of material from above the cuff down into the distal respiratory tract. An innovative solution is to change the shape of the cuff to a fully tapered design, which is found on the Mallinckrodt^TM TaperGuard^TM and SealGuard^TM endotracheal tube lines. This ensures that at some point in the expanded cuff, the cuff diameter will approximate the tracheal diameter and channels will be reduced. Multiple studies have demonstrated decreased leakage with these two new endotracheal tube cuffs.

In your view, what do we (hospitals, healthcare organizations) need to do in order to achieve a dramatic reduction in the incidence of post-intubation pulmonary complications?

The most studied post-intubation pulmonary complication is VAP, though there are likely many others. Hospitals should consider using strategies that work to fight the mechanism of action of these complications, such as the microaspiration of subglottic secretions.

What should a healthcare organization look for when choosing a supplier of mechanical ventilation and respiratory care devices?

Healthcare organizations should consider partnering with a supplier that has a long track record of focusing on the clinician's needs, as well as on both clinical and economic value. It is not enough to provide devices that improve outcomes; they must do so cost-effectively. Covidien is committed to developing products that provide clinical value as well as help reduce healthcare costs and length of stay.

Biography

Douglas Hansell, M.D., M.P.H., is Vice President and Chief Medical Officer for Covidien Respiratory and Monitoring Solutions. A Harvard-based physician, Dr. Hansell has more than 20 years of multi-sector healthcare experience. In addition, Hansell has maintained an active clinical practice in anesthesiology at Massachusetts General Hospital in Boston and has held teaching appointments at Harvard University. Hansell is board certified in Internal Medicine and anesthesiology, fellowship trained in cardiovascular anesthesia and experienced in critical care medicine.