1. CUSP 4 MVP-VAP: Subglottic Suction ETT Implementation

2. Presentation Objectives
To review the evidence to support the implementation of Subglottic Suctioning ETTs using the 4E model.

3. Subglottic Suctioning
VAP is widely thought to be a consequence of modern endo-tracheal tube/tracheostomy tube design
Early devices used high pressure, low volume cuffs
This had the risk of causing tracheal mucosal ischemia and necrosis
To prevent this, high volume low pressure cuffs replaced them
Unfortunately, this along with the newer cuffs’ “barrel” shape allows any secretions that pooled below the vocal cords but above the cuff to leak around the cuff into the lungs.

4. Subglottic Suctioning ETTs
Valles J, et al. Ann Intern Med ;122:179.

5. Subglottic suctioning ETTs in patients mechanically ventilated for >72 hours

6. CDC; MMWR Recomm Rep. 2004;53:1-36
Subglottic suctioning ETTs: Recommended by all VAP Prevention Guidelines
CDC; MMWR Recomm Rep. 2004;53:1-36
ATS/IDSA; AJRCCM 2005;171(4):
Canadian VAP Prevention Guidelines; J Crit Care 2008;23(1):
SHEA; ICHE 2008;29:S31-S40.
The shea ref needs to be udpated for the 2014 compendium. Would add sub bullet that it is a ‘basic practice’

7. Subglottic Suctioning ETTs: More Recent Evidence
13 RCTs evaluating subglottic secretion drainage (2442 patients)
Overall 45% VAP reduction
RR 0.55 (95% CI 0.46–0.66)
NNT = 11
1.5 day ICU LOS reduction
1.1 day duration of MV reduction
Muscedere J. Crit Care Med ;39:1985.

8. Subglottic Suctioning ETTs: Cost Effectiveness Analyses
“Regular utilization of CSS-ETs may produce significant cost savings, irrespective of the increased costs of CSS-ETs.”
Shorr et al. Chest 2001;119:
“CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.”
Hallais et al. ICHE 2011;32(2):

9. Strategy at Johns Hopkins
Identify high risk areas and replace standard ETT with Subglottic Suctioning ETTs.
All intubations in ED, ICU (except for brief procedure), codes on floor
High risk surgical procedures in OR: TAA, liver transplants, anticipated postop open abdomen…
Learn from defects: daily process measures allows teams to identify location of ETT placement