Is patient intubated? He or she is at risk for VAP

Many intensive care units (ICUs) are making changes to prevent ventilator-associated pneumonia (VAP), but what about the ED?

"Staying up-to-date on clinical practice changes in the ICU is important for the emergency nurse, especially if the intubated patient remains in the ED waiting for a bed," says Erin Aston, RN, BSN, an emergency nurse in the children's ED at WakeMed in Raleigh, NC. To prevent VAP in your ED, make these changes:

• Use a Hi-Lo Tracheal tube (Nellcor; Boulder, CO) when intubating patients, instead of a standard endotracheal tube.

"When my unit started the fight to prevent VAP years ago, we made sure that Hi-Lo endotracheal tubes [ETT] were in the crash cart and made available to the health care professional preparing to intubate," says Aston. "The Hi-Lo ETT has a suction port on the tube that allows for continuous suction of subglottic secretions that can pool in the throat. A standard ETT does not have this function."

• Elevate the head of the patient's bed.

"Avoid leaving the patient flat and supine. Instead, utilize lateral rotation and elevate the head of the bed," says Glenn Carlson, MSN, ACNP-BC, CCRN, a clinical nurse specialist/acute care nurse practitioner for critical care at Bronson Methodist Hospital in Kalamazoo, MI.

This step is important to prevent aspiration, says Aston. "Place signs at each bedside to remind the health care profession to elevate the head of the bed 30 degrees, unless this may be contraindicated by the patient's condition, such as trauma patients with spinal injuries or any patient that has an unstable blood pressure. This can also be added to standing order sets."

• Provide frequent oral care and suctioning.

"Every two hours, perform oral care. Brush the patient's teeth, and use [chlorhexidine gluconate] oral rinse," says Carlson.

This practice change can be difficult for the ED nurse, however, compared to ICU nurses. "In the ED, sometimes we have to address the most urgent needs. Other aspects may be performed later, such as mouth care," says Aston. "The ICU is more of a controlled environment compared to the ED. If the nurse cannot perform the oral care due to other more pressing issues, possibly this care can be delegated to the nurse technician."


For more information on preventing ventilator-associated pneumonia, contact:

  • Erin Aston, RN, BSN, Children's Emergency Department, WakeMed, Raleigh, NC. E-mail:
  • Glenn Carlson, MSN, ACNP-BC, CCRN, Emergency Department, Bronson Methodist Hospital, Kalamazoo, MI. Phone: (269) 341-8424. E-mail:

For more information on the Hi-Lo Tracheal tube, contact:

For more information on the Mallinckrodt SealGuard Evac, contact:

Clinical Tip

ED advised to switch to a CASS endotrachial tube

ED nurses at Bronson Methodist Hospital in Kalamazoo, MI, recently began using the continuous aspiration of subglottic secretion (CASS) endotracheal tube (the Mallinckrodt SealGuard Evac, manufactured by Covidien; Mansfield, MA) for patients at high risk for ventilator-associated pneumonia (VAP).

The CASS tubes are now used for neurocritical, trauma, and burn patients instead of a regular endotracheal tube. "There is some literature that this decreases VAP," says Glenn Carlson, MSN, ACNP-BC, CCRN, a clinical nurse specialist/acute care nurse practitioner in the ED. "While earlier CASS tubes were linked to prevention of VAP that occurs within six days, newer versions might assist in prevention for all VAPs."1


  1. Bouza E, Perez MJ, Munoz P, et al. Continuous aspiration of subglottic secretions in the prevention of ventilator associated pneumonia in the postoperative period of major heart surgery. Chest 2008; 134:898-900.