Ventilator-associated events in children: A multicentre prospective cohort study

Outcomes associated with ventilator-associated events (VAE), respiratory infections (VARI), pneumonia (VAP) and tracheobronchitis (VAT) in ventilated pediatric ICU patients: A multicentre prospective cohort study

OBJECTIVES

An objective categorization of respiratory infections based on outcomes is an unmet clinical need. Ventilator-associated pneumonia and tracheobronchitis remain used in clinical practice, whereas ventilator-associated events (VAE) are limited to surveillance purposes.

RESEARCH METHODOLOGY/DESIGN

This was a secondary analysis from a multicentre observational prospective cohort study. VAE were defined as a sustained increase in minimum Oxygen inspired fraction (FiO2) and/or Positive end-expiratory pressures (PEEP) of ≥ 0.2/2 cm H2O respectively, or an increase of 0.15 FiO2 + 1 cm H20 positive end-expiratory pressures for ≥ 1 calendar-day.

SETTING

15 Paediatric Intensive Care Units.

MAIN OUTCOME MEASURES

Mechanical ventilation duration, intensive care and hospital length of stay; (LOS) and mortality.

RESULTS

A cohort of 391 ventilated children with an age (median, [Interquartile Ranges]) of 1 year[0.2-5.3] and 7 days[5-10] of mechanical ventilation were included. Intensive care and hospital stays were 11 [7-19] and 21 [14-39] days, respectively. Mortality was 5.9 %. Fifty-eight ventilator-associated respiratory infections were documented among 57 patients: Seventeen (29.3 %) qualified as ventilator-associated pneumonia (VAP) and 41 (70.7 %) as ventilator-associated tracheobronchitis (VAT). Eight pneumonias and 16 tracheobronchitis (47 % vs 39 %,P = 0.571) required positive end-expiratory pressure or oxygen increases consistent with ventilator-associated criteria. Pneumonias did not significantly impact on outcomes when compared to tracheobronchitis. In contrast, infections (pneumonia or tracheobronchitis) following VAEs criteria were associated with > 6, 8 and 15 extra-days of ventilation (16 vs 9.5, P = 0.001), intensive care stay (23.5 vs 15; P = 0.004) and hospital stay (39 vs 24; P = 0.015), respectively.

CONCLUSION

When assessing ventilated children with respiratory infections, VAE apparently is associated with higher ventilator-dependency and LOS compared with pneumonia or tracheobronchitis.

IMPLICATIONS FOR PRACTICE

Incorporating the modification of ventilatory settings for further categorization of the respiratory infections may facilitate therapeutic management among ventilated patients.

Ventilator-associated events in adults: A secondary analysis assessing the impact of monitoring ventilator settings on outcomes

BACKGROUND

Ventilator-associated events (VAE) is a tier implemented for surveillance by the CDC in the USA. Implementation usefulness for clinical decisions is unknown.

METHODS

We conducted a secondary analysis from a prospective, multicentre, international study, to assess the impact on outcomes of using tiers with shorter follow-up (VAE24), lower oxygenation requirements (light-VAE) or both (light VAE24).

RESULTS

A cohort of 261 adults with 2706 ventilator-days were included. The median (IQR) duration of mechanical ventilation (MV) was 9 days (5-21), and the median (IQR) length of stay in the intensive care unit (ICU) was 14 days (8-26). A VAE tier was associated with a trend to increase from 32% to 44% in the ICU mortality rates. VAE Incidence was 24 per 1,000 ventilator-days, being increased when reduced the oxygenation settings requirement (35 per 1,000 ventilator-days), follow-up (41 per 1,000 ventilator-days) or both (55 per 1,000 ventilator-days). A VAE tier was associated with 13 extra (21 vs. 8) days of ventilation, 11 (23 vs. 12) ICU days and 7 (31 vs. 14) hospitalization days, outperforming the modified tiers' performance.

CONCLUSIONS

The modification of ventilator settings (consistent with ventilator-associated events) was associated with worse outcomes among adults with prolonged mechanical ventilation. Monitoring ventilator-associated events at the bedside represents a new tool for quality improvement.

Prevention of ventilator-associated pneumonia through care bundles: A systematic review and meta-analysis

Background

Ventilator-associated pneumonia (VAP) represents a common hospital-acquired infection among mechanically ventilated patients. We summarized evidence concerning ventilator care bundles to prevent VAP.

Methods

A systematic review and meta-analysis were performed. Randomized controlled trials and controlled observational studies of adults undergoing mechanical ventilation (MV) for at least 48 h were considered for inclusion. Outcomes of interest were the number of VAP episodes, duration of MV, hospital and intensive care unit (ICU) length of stay, and mortality. A systematic search was conducted in the MEDLINE, the Cochrane Library, and the Web of Science between 1985 and 2022. Results are reported as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI). The PROSPERO registration number is CRD42022341780.

Results

Thirty-six studies including 116,873 MV participants met the inclusion criteria. A total of 84,031 participants underwent care bundles for VAP prevention. The most reported component of the ventilator bundle was head-of-bed elevation (n=83,146), followed by oral care (n=80,787). A reduction in the number of VAP episodes was observed among those receiving ventilator care bundles, compared with the non-care bundle group (OR=0.42, 95% CI: 0.33, 0.54). Additionally, the implementation of care bundles decreased the duration of MV (MD=-0.59, 95% CI: -1.03, -0.15) and hospital length of stay (MD=-1.24, 95% CI: -2.30, -0.18) in studies where educational activities were part of the bundle. Data regarding mortality were inconclusive.

Conclusions

The implementation of ventilator care bundles reduced the number of VAP episodes and the duration of MV in adult ICUs. Their application in combination with educational activities seemed to improve clinical outcomes.

Ventilator-associated events: From surveillance to optimizing management

Mechanical ventilation (MV) is a life-support therapy that may predispose to morbid and lethal complications, with ventilator-associated pneumonia (VAP) being the most prevalent. In 2013, the Center for Disease Control (CDC) defined criteria for ventilator-associated events (VAE). Ten years later, a growing number of studies assessing or validating its clinical applicability and the potential benefits of its inclusion have been published. Surveillance with VAE criteria is retrospective and the focus is often on a subset of patients with higher than lower severity. To date, it is estimated that around 30% of ventilated patients in the intensive care unit (ICU) develop VAE. While surveillance enhances the detection of infectious and non-infectious MV-related complications that are severe enough to impact the patient's outcomes, there are still many gaps in its classification and management. In this review, we provide an update by discussing VAE etiologies, epidemiology, and classification. Preventive strategies on optimizing ventilation, sedative and neuromuscular blockade therapy, and restrictive fluid management are warranted. An ideal VAE bundle is likely to minimize the period of intubation. We believe that it is time to progress from just surveillance to clinical care. Therefore, with this review, we have aimed to provide a roadmap for future research on the subject.