Ventilator-associated tracheobronchitis—VAT for
short—is a lower respiratory infection caused by a buildup of bacteria
in the airway. Ordinarily, these small organisms are easily cleared, but
being on a ventilator with an artificial airway in place disrupts the
body's natural defenses. This, along with other factors, increases the
risk of VAT, says Jennifer Muszysnki, lead study author and a critical
care physician and principal investigator in the Center for Clinical and
Translational Research in The Research Institute at Nationwide
Children's.
Historically, VAT infections have not been tracked as closely as
another common airway infection known as VAP—ventilator-associated
pneumonia—which has been monitored by the Centers for Disease Control
and Prevention in Atlanta for more than a decade and is a common target
for quality improvement initiatives in hospitals across the country.
A program instituted in 2007 at Nationwide Children's to prevent VAP
in ventilated pediatric intensive care patients led to a dramatic
decline in VAP rates. However, physicians found that many children still
required treatment for ventilator-associated airway infections that did
meet the CDC criteria for VAP. So, in 2010, Muszysnki and her
colleagues decided to adapt the VAP prevention program to study its
effectiveness on reducing VAT.
The new plan included a bundle of patient care components. Ventilated patients' beds were raised to a 30-degree angle at the head, which helps reduce bacteria in the airway. Patients were given an anti-bacterial oral rinse every four hours, and respiratory therapists followed a strict process for suctioning secretions from patients' mouths and throats. A multidisciplinary team of respiratory therapists, physicians and nurses met regularly to monitor patients' progress.
After 18 months, the cases of VAT had dropped by 53 percent compared to pre-intervention rates.
"The multidisciplinary approach that was key to this success,"
Muszynski says, adding that because each team member interacted
differently with the patient and brought a unique perspective, barriers
to bundle implementation could be identified and solved quickly.
This is among the first published studies on VAT prevention in
pediatric patients. While there is good information to be mined from the
data, Musyznki says that this only grazes the surface of the problem.
"We still want to understand why some children get VAT and others
don't, or why one child will have a mild case while another gets very
sick, even when both have the benefit of the same preventive protocol,"
says Muszynski, who also is an assistant professor of pediatrics at The
Ohio State University College of Medicine. "There are many more
questions we'd like to answer."