The Science: This is a retrospective review chart of patients who were intubated by emergency personnel (both EMS and ED) over a one-year period and were admitted to the intensive care unit (ICU) and developed ventilator acquired pneumonia (VAP). A total of 901 patients were admitted to the ICU, with 112 being intubated by emergency personnel, of which 37 (n = 75) were excluded because of early death, with pneumonia as the primary diagnosis or extubation within 48 hours. A total of 15 patients developed VAP, or a prevalence rate of 20%.
Investigators found that cardiac arrest, out-of-hospital location, and aspiration at time of intubation were all associated with VAP. Death was not statistically significant; however, the length of ICU stay was: 11 days for VAP patients versus four days for non-VAP patients.
Dr. Wesley: This is a very interesting study. Those that promote the use of prehospital intubation frequently state that the ET tube is the “gold standard” because it limits the complication of aspiration pneumonia. However, this study indicates that it’s not the ET tube, but the setting of the intubation that is related to ventilation-associated pneumonia (VAP).
Although there are no comparable studies that discuss the incidence of VAP of the prehospital ET with a supraglottic airway, this study would suggest that even though the incidence of VAP is higher in the field intubation, the clinical result is not significant. The death rate was the same for the ED and EMS intubations.
The authors suggest that the promulgation of various preventive strategies could lower this rate. Some of these strategies include non-invasive ventilation, better suctioning of the airway prior to intubation, ensuring proper cuff pressure of the tube, and attempting to keep the patient’s head elevated. Although all these strategies make sense, how they can be implemented in the austere EMS environment is questionable.
What I take from this report is that VAP isn’t a major cause of clinical concern when compared with the patient’s underlying condition and need for airway management. Modern medicine has the ability to treat VAP when it occurs. If anything, this study should alert physicians that care for these patients in the ICU to be extra vigilant in suspecting the occurrence of VAP and treat the patient prophylactically.
Medic Marshall: Like the Doc said, this is a very interesting study, and it definitely provides us with some things to think about as EMS providers. First of all, this is the first time I’ve seen a study that looks at a complication that we (paramedics) have no control over, which is infection.
So even if we all had 100% success rates on endotracheal intubation, we’re still putting patients at great risk of infection, which could lead to longer ICU stays. Although the study was not able to demonstrate statistical significance in death rate, it should make you at least stop and think that it may have some clinical implications. Why put these patients at risk at all?
The other issue I have is the length of ICU stay. The study showed those with VAP had much longer stays (11 vs. four days). In our current state of healthcare, with a movement toward preventative medicine and reducing healthcare costs, this could have a tremendous financial effect on hospitals.
As part of the healthcare system (whether you agree with me or not), I believe we also need to help out and reduce the cost of healthcare—now.
We don’t know what the prevalence of VAP with supraglottic airways are as compared with ETI. So for you aspiring researchers out there, this would be a great topic to research.
I don’t think we need to completely change our practice based on this paper, but it should definitely motivate us to find a better alternative to airway management. It seems to me the risk of ETI in the hands of emergency personnel is only increasing. At what point do we say, ‘enough is enough?’
Decelle L, Thys Fre’ de’ ric, Verschuren F. Ventilation-associated pneumonia after intubation in the prehospital or the emergency unit. Eur J of Emerg Med. 2011;12 [Epub ahead of print.]
The aim of the study was to evaluate the prevalence and the risk factors of ventilation-associated pneumonia (VAP) for out-of-hospital or in the emergency department intubated patients.
This was a retrospective descriptive study. All intubated adults subsequently admitted to the ICU over 1-year period were included. Among the 75 patients, 15 patients developed VAP (20%; 95% CI 12–31%). A multivariate analysis revealed three variables independently associated with VAP: cardiorespiratory arrest as the reason of intubation (P =0.001), out-of-hospital as the location of intubation (P = 0.011), and clinical macroaspiration as clinical characteristic at the time of intubation (P = 0.024). Death rate was 17% and was not significantly higher for patients with VAP (P= 0.9; 95% CI 0.32–4.95%).
Emergency care workers should be aware of the potential 20% occurrence of VAP when they intubate and ventilate a patient. Preventive strategies, which have been proven effective in ICUs, should be implemented in the emergency setting.