Frequent Versus Infrequent Monitoring of Endotracheal Tube Cuff Pressures.

BACKGROUND: Currently there is no accepted standard of practice for the optimal frequency of endotracheal tube cuff pressure monitoring in mechanically ventilated patients. Therefore, we conducted a study to compare infrequent endotracheal tube cuff pressure monitoring (immediately after intubation and when clinically indicated for an observed air leak or due to tube migration) with frequent endotracheal tube cuff pressure monitoring (immediately after intubation, every 8 h, and when clinically indicated). METHODS: We performed a prospective clinical trial with subjects assigned to study groups based on room assignment. The primary outcome was the occurrence of a ventilator-associated event (VAE) and was adjudicated by individuals blinded to the conduct of this study. RESULTS: We enrolled 305 subjects, with 166 (54.4%) assigned to frequent monitoring and 139 (45.6%) assigned to infrequent monitoring. The total number of endotracheal tube cuff pressure monitoring events for both groups was 1,531 versus 336, respectively. The occurrence of VAEs was infrequent and similar for both groups (3.6% vs 5.8%, P = .37). Witnessed aspiration events (0.6% vs 0%, P = .36), ventilator-associated pneumonia (0% vs 0.7%, P = .27), 30-d mortality (31.3% vs 30.2%, P = .83), and hospital length of stay (10 d [6 d, 21 d] vs 11 d [6 d, 21 d], P = .34) were also similar for both study groups. The 30-d hospital readmission rate was statistically lower for the group that received infrequent monitoring (15.1% vs 6.5%, P = .02). CONCLUSIONS: More frequent cuff pressure monitoring was not associated with any identifiable clinical outcome benefit.

A Respiratory Therapist Disease Management Program for Subjects Hospitalized With COPD.

BACKGROUND: Patients with COPD often require repeated emergency department visits and hospitalizations for COPD exacerbations. Such readmissions increase health-care costs and expose COPD patients to the added risks of nosocomial infections and increased mortality. METHODS: To determine whether a respiratory therapist (RT) disease management program could reduce re-hospitalization and emergency department visits, a prospective, single-center, unblinded, randomized trial was performed. RESULTS: We enrolled 428 subjects (214 intervention, 214 control). The primary outcome (combined non-hospitalized emergency department visits and hospital readmissions for a COPD exacerbation during the 6-month follow-up) was similar for the study groups (91 vs 159, P = .08). When the 2 components of the primary end point were analyzed individually, the percentage of subjects with non-hospitalized emergency department visits for COPD exacerbations was similar between groups (15.0% vs 15.9%, P = .79). Readmission for a COPD exacerbation was significantly lower in the intervention group (20.1% vs 28.5%, P = .042). The median (interquartile range) duration of hospitalization for a COPD exacerbation was less for the intervention group (5 [3-11] d vs 8 [4-18.5] d, P = .045). In-patient hospital days (306 d vs 523 d, P = .02) and ICU days (17 d vs 53 d, P = .02) due to COPD exacerbations were significantly less for the intervention group. Mortality was similar for both groups (1.4% vs 0.9%, P > .99). CONCLUSIONS: Our RT disease management program was associated with less readmission, fewer ICU days, and shorter hospital stays due to COPD exacerbations. Further studies are needed to determine the optimal utilization of RT disease management teams for patients with COPD to optimize outcomes and prevent return hospital visits. (ClinicalTrials.gov registration NCT01543217.).

Use of a Shared Canister Protocol for the Delivery of Metered-Dose Inhalers in Mechanically Ventilated Subjects.

BACKGROUND: Mechanically ventilated patients often need bronchodilators administered via a metered-dose inhaler (MDI). Unfortunately, there are no data examining the impact of shared canister delivery of MDI therapy in mechanically ventilated patients. METHODS: A prospective trial was conducted with subjects assigned to shared canister MDI therapy or single-patient canister MDI therapy. Outcomes assessed were occurrence of ventilator-associated pneumonia (VAP), hospital mortality, length of stay, ventilator-associated events, and MDI costs. RESULTS: Among 486 screened patients, 353 were included for analysis of which 201 (56.9%) received shared canister MDI therapy and 152 (43.1%) received single-patient canister therapy. VAP (7.0% vs 4.6%, P = .35), hospital mortality (21.9% vs 20.4%, P = .73), and ventilator days (median [interquartile range] 3.1 [0.9-7.5] d vs 2.7 [1.2-7.1] d, P = .62) were similar between the shared canister and single-patient canister groups. We did not observe clinically important differences for ventilator-associated events between study groups in our logistic regression analysis (P = .07). There was a savings of $217/subject in the shared canister group due to the use of 299 fewer MDIs. CONCLUSIONS: Our study found that shared canister MDI therapy compared with single-patient MDI use was associated with a significant cost savings and similar rates of VAP, hospital mortality, and length of stay but a greater prevalence of ventilator-associated events. This finding suggests that shared canister delivery of MDIs may be a cost-effective practice in mechanically ventilated patients. Based on our findings, further studies examining the overall safety of shared canister use in mechanically ventilated patients seem warranted before recommending their routine use. (ClinicalTrials.gov registration NCT01935388.).