Vyaire tri flo subglottic suctioning external presentation v4

This is a presentation that I gave recently on the value of subglotic suctioning vs Sub Glottic ET tube placement. Key to the use of this system is reduced hospital acquired condition and positive impact on hospital length of stay. This is a system that should be evaluated by any respiratory dept that is interested in reducing hospital acquired infections associated with Mechanical ventilation

1. Tri-Flo™ Subglottic Suction System

2. Disclosures Randy Clare is employed by Vyaire Medical

3. Objectives Anatomy and Intubation Overview Aspirations Risks and Ventilator Associated Pneumonia (VAP) Bundles Understanding Clinical Data What is Subglottic Suctioning How is it being done today? Pros and Cons Is Oral Care the Same as Subglottic Suctioning? Vyaire Medical Tri-Flo™ Subglottic Suction System Branson Study Tri-Flo Subglottic Suction ROI

4. Anatomy and Intubation Overview

5. Anatomy Overview: Upper vs. Lower Airway Oral cavity https://upload.wikimedia.org/wikipedia/commons/thumb/9/9f/Illu_conducting_passages.svg/500px-Illu_conducting_passages.svg.png

6. Nose - Mouth - Pharynx Pharynx Muscular tube, lined with mucous membrane, that connect the oropharynx (mouth), Nasopharynx (nose) and hypopharynx (throat). Nasopharynx Uppermost part of the pharynx and always remains patent . Oropharynx Extends from the Uvula to the hyoid bone. Hypopharynx/Laryngopharynx Part of the throat that forms from the epiglottis to the esophagus. Epiglottis closes over the glottis when food is swallowed to prevent aspiration. Oral Cavity Nasal and Oral Cavities . - http ://www.mayoclinic.org/-/media/kcms/gbs/patient-consumer/images/2013/11/15/17/35/ds00349_-ds00756_im00110_c7_nasopharynxthu_jpg.ashx - https ://en.wikipedia.org/wiki/Respiratory_tract#Upper_respiratory_tract

7. Key Landmark - Upper A irway: Vocal Cords Vocal Cords http://what-when-how.com/wp-content/uploads/2012/04/tmp26117.jpg

8. Upper Airway M anagement - Larynx Larynx The Larynx is an organ in the neck involved in: B reathing S ound production P rotecting the trachea against food aspiration The larynx houses the vocal cords S ituated just below the tract where the pharynx splits into the trachea and the esophagus . - https ://en.wikipedia.org/wiki - https ://www.cancer.gov/images/cdr/live/CDR716231-571.jpg

9. Oro pharyngeal Space Oropharyngeal – part of the pharynx between the soft palate and hyoid bone Soft palate Hyoid Subglottic - https ://en.wikipedia.org/wiki/Hyoid_bone - https ://en.wikipedia.org/wiki/Soft_palate - https ://en.wikipedia.org/wiki/Pharynx

10. Vocal Cords and Epiglottis Anterior Anterior Posterior Posterior Epiglottis https://en.wikipedia.org/wiki/Vocal_folds

11. Subglottic Subglottic Area The lower part of the larynx , extending from just beneath the vocal cords to the top of the trachea Vocal cords are in the “ glottic” region of the larynx Oropharyngeal = Subglottic https://en.wikipedia.org/wiki/Subglottis

12. Anterior Opening of Vocal Cords http://youtu.be/Vl5IBNzIlfU

13. Upper airway management - Nerves Two Nerves to highlight for airway management: Vagus Nerve Very sensitive nerve Regulates heart rate If over stimulated when suctioning or intubating may lower heart rate Glossopharyngeal Nerve Sensation to the palate, tongue & upper throat Swallowing, gagging reflex - https ://en.wikipedia.org/wiki - https ://en.wikipedia.org/wiki/Glossopharyngeal_nerve - https ://en.wikipedia.org/wiki/Vagus_nerve

14. Endotracheal Intubation Procedure performed by trained personnel Various taping methods, materials and devices used to secure the ETT Hollister Bite blocks Skin friendly tape/duoderm Anatomy of an endotracheal tube: Airway adapter Breathing tube Pilot line and balloon, cuff inflation ETT cuff Beveled tip Calibration markings Standard Endotracheal Tube Pilot line ETT Cuff - https ://en.wikipedia.org/wiki/Tracheal_intubation - http ://www.bing.com/images/search?view=detailV2&ccid=obM9oPCZ&id=F34D7B2378A504584A5EA35EB860434679816E8B&thid=OIP.obM9oPCZBxFHBB7rR2ds-QEsCc&q=endotracheal+tube+&simid=607988773199809789&selectedIndex=0&ajaxhist=0

15. Subglottic Endotracheal Tube Anatomy of Subglottic ETT: Airway adapter Breathing tube Pilot line and balloon, cuff inflation ETT cuff Suction line (yellow tip) Open suction port just above cuff Beveled tip Calibration markings Pilot line Suction line Suction Port - http ://www.bing.com/images/search?view=detailV2&ccid=xx%2bVPdZI&id=9ADC0B3F3639CFE97EA6B802465ACC8A4108F73A&thid=OIP.xx-VPdZIwtkw7Mle_ylyQwDEEs&q=subglottic+endotracheal+tube&simid=607985985780973650&selectedIndex=0&ajaxhist=0 - http ://www.rcjournal.com/contents/08.10/08.10.1046.pdf

16. Intubation Common Indications Inability to protect airway Surgical procedure Respiratory/cardiac arrest Respiratory failure Drug delivery: surfactant administration Contra-Indications Total upper airway obstruction Serious maxillofacial trauma Inability to open the mouth Rapid Sequence Intubation Updated: Mar 24, 2017; eMedicine Medscape

17. Complications of Intubation Inappropriate size or placement of ETT can lead to: Injury to the vocal cords Trauma to the upper/lower airway Accidental intubation of the esophagus Broken teeth or dentures Rapid Sequence Intubation Updated: Mar 24, 2017; eMedicine Medscape

18. Site of Action Procedure Description Frequency Benefit Product Oral Care Mouth Brush teeth followed by antiseptic rinse, moisturize and oral suction as needed Minimize formation of bacteria in oropharynx Brush/rinse 2x/shift Antiseptic/moisturizer 2x/shift Infection Prevention / HAIs SAGE Oral Care Oral-Pharyngeal Suction Mouth or Throat (oral cavity and above the vocal cords) Catheter inserted into mouth or back of throat Remove secretions from the mouth or pharynx PRN / Q12 hrs Maintain patency of oral cavity and oropharynx Standard suction catheter (Oral Care or Open Suction) o r Yankauer device Subglottic Suction Subglottic (below vocal cords, outside of artificial airway and above the ETT cuff) Catheter inserted into subglottic area just above ETT cuff Remove secretions pooled above ETT cuff Continuous low vacuum pressure; Q3-Q8 intermittent @ 120-150 mmHG Potentially reduce aspiration risk and Healthcare Acquired Pneumonia Tri-Flo Subglottic Suction System Closed Suction Trachea (below vocal cords, within artificial airway and below the cuff) Catheter inserted into an artificial airway Remove secretions within the ETT , tracheostomy tube and trachea Not routinely, only when clinically indicated Maintain patency of artificial airway (ETT or Trach tube) Clarity Closed Suction System Airway Clearance Methods - Reducing VAP and HAP Risk Factors https://sageproducts.com/clinical-information-reducing-vaphap-risk-factors/ - Clinical Procedures for Safer Patient Care. Doyle.chapter5.8 Oral Suctioning. https://opentextbc.caclinicalskills/chapter5.7oralsuctioning - Preliminary evaluation of a novel strategy to aspirate subglottic secretions. Bassi intensive care medicine experimental 2016 - AARC Clinical Practice Guideline Endotracheal Suctioning of Mechanically Ventilated Patients with Artificial Airways 2010

19. Areas of Secretion Management Oral care Oral-Pharyngeal Suction Subglottic Suction Closed Suction http://data.allenai.org/tqa/the_respiratory_system_L_0393/

20. Aspiration Risks and Ventilator Associated Pneumonia (VAP) Bundles

21. Topics What is mucus? “Mucus” vs. “Sputum” The function of mucus in the airway How is mucus removed from the airway Possible consequences of ineffective mucus clearance could lead to Ventilator Associated Pneumonia (VAP) - https ://www.ncbi.nlm.nih.gov/pubmed/12510824) - Arch Pharm Res. 2002 Dec;25(6):770-80 - https ://www.quora.com/What-is-the-difference-between-phlegm-and-sputum

22. Micro-aspirations Micro-aspiration is a major cause of VAP What is it ? inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract – patient reacts by coughing or clearing throat “Silent” micro-aspiration when patients have asymptomatic aspiration of small volumes of oropharyngeal secretions or gastric fluid into their lungs – patient does not react or cough http://youtu.be/huZ6ymeKFd4 - Aspiration Syndromes Clinical Presentation: History, Physical, Causes emedicine.medscape.com/article/1005303 - Silent aspiration: what do we know? – NCBI https://www.ncbi.nlm.nih.gov/pubmed/16362510

23. How to Avoid Micro-aspirations Taking into account the effectiveness of avoiding micro-aspiration in avoiding VAP the following measures should be considered Use of ETT designed for SSD Subglottic Suction System Continuous cuff pressure monitoring and control Minimum PEEP of 5 cmH 2 O Avoidance of supine positioning Pulmonary toilet Adequate Oral Care How to avoid Microaspiration? BMC Infectious Diseases201414:119; DOI: 10.1186/1471-2334-14-119;  Blot et al.; licensee BioMed Central Ltd. 2014

24. What could cause micro-aspirations? Open discussion

25. What Can Cause Micro-aspirations? O ropharyngeal secretions and gastric fluid Manipulation/disconnection of the ventilator circuits Changes in cuff pressure Cuff leak testing Wrinkles in the ETT cuff ETT manipulation - www.healthline.com/health/aspiration-pneumonia - https ://www.ncbi.nlm.nih.gov/pubmed/16362510 - emedicine.medscape.com/article/1005303

26. When to Use What Term HAI/VAE/VAP

27. HAI vs. VAP Healthcare-associated infections ( HAIs) I nfections patients can get while receiving medical treatment in a healthcare facility On any given day, about one in 25 hospital patients has at least one healthcare-associated infection . Pneumonia gastrointestinal illness urinary tract infections bloodstream infections surgical site infections Ventilator-associated Pneumonia (VAP) is one of many types of HAIs Specific to mechanically ventilated patients https://www.cdc.gov/hai/surveillance/index.html

28. VAP Definition In September 2011, the Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group. Changes include: Clinically defined as pneumonia that occurred during mechanical ventilation Pneumonia occurs 48 hours or more after being placed on ventilator New VAE definitions based on Fi0 2 /PEEP value increases, clinical factors (temp/CXR), microbiological factors (sputum sample) Ventilator-associated pneumonia in the ICU; Kalanuria et al . Critical Care 2014, 18:208; http://ccforum.com/content/18/2/208

29. Consequences of VAP Between 250,000 and 300,000 cases per year occur in the United States alone, which is an incidence rate of 5 to 10 cases per 1,000 hospital admissions The mortality attributable to VAP has been reported to range between 0 and 50% Beyond mortality, the economics of VAP include increased ICU lengths of stays ( LOS), increased mechanical ventilation and increased antibiotic use Average cost of an ICU ventilator day on day 3 is $3,968 Estimates for cost of VAP range from $10,000 to over $40,000 - Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention Clinical Microbiol Rev. 2006 Oct; 19(4):637-657 - Daily cost of an intensive care unit day: The contribution of mechanical ventilation* Joseph F. Dasta, MSc, FCCM; Trent P. McLaughlin, PhD;

30. Just part of the equation… Bundles to prevent ventilator-associated pneumonia: https://www.ncbi.nlm.nih.gov/pubmed/19276975

31. Ventilator Bundle Techniques to Avoid VAP HOB HOB is elevated at 30 degrees unless medically contraindicated Reduces aspiration of oropharyngeal/gastric secretions Mobility Turn Q 2 hrs./ Out of bed when appropriate Mobilizes secretions Oral Care Perform Oral Care Q 2 hrs. following structured oral care protocol Removes pathogens from oropharynx Subglottic Suctioning Pulmonary Toileting as needed Sedation Vacation Hand Hygiene Bundles to prevent ventilator-associated pneumonia: https://www.ncbi.nlm.nih.gov/pubmed/19276975

32. Changing Views of VAP/VAE No longer just an “unfortunate” occurrence Viewed as medical error Institute of Medicine Leapfrog Group The Joint Commission – hospitals required to show VAP prevention/reduction measures Centers for Disease Control and Prevention (CDC ), Sept. 2011

33. Value and Review of Clinical Data

34. Disclaimer: The following studies should only be referenced to support the general proposition that subglottic suctioning can help to reduce VAP. The studies examined subglottic ETTs rather than our product, and therefore you should not state or imply that specific rates or percentages of VAP reduction observed in the studies could be applicable to our product.

35. Scientific Paper Will either entice you to read further or discard. Check the publication date P urpose or rationale of the study: Why, H ow & What H ow the experiment was conducted S tatement of what was found (tables and figures) A ddress what is known, what is not known, and what questions the authors asked and answered P rovides c lear answer to the question posed and explains how the results support that conclusion Review of Clinical Data http://guides.lib.usf.edu/ebp/levels_of_evidence )

36. What Do You Need to Know? Discussions about Scientific Studies: Systematic Reviews (Meta Analysis ) and Randomized Controlled Trials

37. Value of Clinical Data 31 Systematic Review –represents the strongest form of evidence we have! http ://guides.lib.usf.edu/ebp/levels_of_evidence ) Randomized Controlled Trial -the next highest ranked scientific paper

38. Value of Clinical Data How does a Systematic Review (SR) work? Take individual studies and combine them into one review Why use a SR vs other clinical date? Researching a complex issue; SR enables you to look at them all in one place to determine conclusion. SR helps resolve discrepancies Most importantly, when a SR is conducted, you don’t just pick any paper. Papers are picked systematically, with specific inclusion and exclusion criteria P apers are then reviewed by multiple people to prevent any bias Meta-analysis is a subset of SR. Data from all the studies used in SR and pool it together for evaluation http://guides.lib.usf.edu/ebp/levels_of_evidence )

39. Literature Review “Subglottic Secretion Drainage for Preventing Ventilator Associated Pneumonia: A systematic review and meta-analysis” Critical Care Med, J Muscedere 2011 Study Summary This study performed a comprehensive, systematic review and meta-analysis of RCT of mechanically ventilated patient’s comparing standard endotracheal tubes to those with subglottic secretion drainage and reporting on the occurrence of VAP. Studies were meta-analyzed for the primary outcome of VAP and secondary clinical outcomes such as duration of MV, LOS (ICU and hospital), mortality, and adverse events. Of the 1209 studies retrieved, 13 met the inclusion criteria with a total of 2,442 patients. Subglottic Secretion Drainage for Preventing Ventilator Associated Pneumonia: A systematic review and meta-analysis” Critical Care Med, J Muscedere 2011

40. Results - Critical Care Med, J Muscedere 2011 Results noted: Reduced the incidence of VAP by 50% Reduced ICU LOS by 1.52 days Decreased duration of MV by 1.08 days Delayed onset of VAP by 2.66 days Subglottic Secretion Drainage for Preventing Ventilator Associated Pneumonia: A systematic review and meta-analysis” Critical Care Med, J Muscedere 2011

41. Literature Review “Prevention of Ventilator-Associated Pneumonia and Ventilator-Associated Conditions: A Randomized Controlled Trial with Subglottic Secretion Suctioning” Critical Care Med , P Damas Jan 2015 Study Summary Randomized controlled clinical trial conducted in five ICUs of the same hospital VAP was determined by quantitative bronchoalveolar lavage cultures VACs was defined by Centers for Disease Control and Prevention criteria “Prevention of Ventilator-Associated Pneumonia and Ventilator-Associated Conditions: A Randomized Controlled Trial with Subglottic Secretion Suctioning ” Critical Care Med , P Damas Jan 2015

42. Results - Critical Care Med, P Damas Jan 2015 Of 352 patients included in the study, 170 patients had ETT-SSD and 182 had ETT. Groups did not differ by demographics, comorbidities by Charlson score, cause of admission, SAPS III score and SOFA score at admission. Patients with ETT-SSD had lower VAP rate (8.8% ETT-SSD vs. 17.6% for ETT, p = 0.018) decreased antibiotic days (61.6% of ICU days vs. 68.5% of ICU days, p = 0.0001) No difference in VAC rates, ICU stay or mortality “ Prevention of Ventilator-Associated Pneumonia and Ventilator-Associated Conditions: A Randomized Controlled Trial with Subglottic Secretion Suctioning ” Critical Care Med , P Damas Jan 2015

43. Clinical Evidence - Recommendations ATS/IDSA 2016 Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society . AACN Ventilator Associated Pneumonia Practice Alert SHEA 2008 Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals APIC 2009 Guide to the Elimination of Ventilator-Associated Pneumonia - Am J Respir Crit Care Med Vol 171. pp388-416, 2005. - https ://www.aacn.org/clinical-resources/practice-alerts/ventilator-associated-pneumonia-vap - Infect Control Hosp Epidemilogy 2014;35(8):915-936 - An Apic Guide; 2009; Guide to the Elimination of Ventilator-Associated Pneumonia

44. What is Subglottic Suctioning

45. How is Subglottic Suctioning Done T oday?

46. Subglottic ETT Pilot line Suction line Suction Port

47. Embedded Suction Port “Above the Cuff ” Subglottic ETT https://tineye.com/

48. Subglottic ET Tubes Hi-Lo “EVAC” and TaperGuard “EVAC” MicroCuff w/Subglottic Suctioning ISIS HVT Portex SACETT Market leader PVC Cuff Tapered cuff shape Thin, p olyurethane cuff Longer length cuff PVC Cuff Suction line is “added-on” to ETT PVC cuff S G ETT ASP = $17

49. Pilot line Suction line Regulator & Suction Canister Subglottic ETT Set-up

50. Vacuum Regulators Precision Medical “Continuous Subglottic Suction Regulator” Simex Subglottic Suction Pump Ohio Medical

51. Intermittent vs. Continuous Suctioning Continuous vacuum: low Intermittent vacuum: 120-150 mmHg Both approaches are supported by literature - Infect Control Hosp Epidemilogy 2014;35(8):915-936 - J Trauma Acute Care Surg. Vol 80, Number 2. - Respir Care 2010; 55(6):758-764

52. Require Upfront Utilization Tube has to be selected at the time of intubation Difficult to predict which patients will be vented >48 hrs. Wide-spread use is expensive and wasteful Difficult to get buy-in across departments Subglottic ETTs - #1 Objection

53. Clogging Tissue entrapment in a single suction port Restricted suction lumen Subglottic ETTs - #1 Complaint AirLife Tri-Flo = 14Fr, round lumen ETT = 12 Fr, ovalized lumen

54. SG ET Tubes Pros Cons Aligns with recommendations of Standard of Care for SG suction, allowing for subglottic secretion drainage Helps reduce micro-aspirations , minimizing potential for VAP Placement occurs a time of intubation One procedure Some SG tubes have a failure rate of 40% Clogs/occludes Larger and stiffer; more difficult to intubate More expensive than standard ET tubes Not selective to specific patients Need to decide at time of intubation Either carry two different ETTs or intubate all patients w/SG tubes No standard of care in protocol - Am J Respir Crit Care Med Vol 171. pp388-416, 2005. - https :// www.aacn.org/clinical-resources/practice-alerts/ventilator-associated-pneumonia-vap - Infect Control Hosp Epidemilogy 2014;35(8): 915-936 - AM J Respir Crit Care Med 1996; 154:111-5

55. Is Oral Care the Same as S ubglottic Suctioning?

56. Site of Action Procedure Description Frequency Benefit Product Oral Care Mouth Brush teeth followed by antiseptic rinse, moisturize and oral suction as needed Minimize formation of bacteria in oropharynx Brush/rinse 2x/shift Antiseptic/moisturizer 2x/shift Infection Prevention / HAIs SAGE Oral Care Oral-Pharyngeal Suction Mouth or Throat (oral cavity and above the vocal cords) Catheter inserted into mouth or back of throat Remove secretions from the mouth or pharynx PRN / Q12 hrs Maintain patency of oral cavity and oropharynx Standard suction catheter (Oral Care or Open Suction) o r Yankauer device Airway Clearance Methods Oral care Oral-Pharyngeal Suction - Reducing VAP and HAP Risk Factors https://sageproducts.com/clinical-information-reducing-vaphap-risk-factors/ - www.sageproducts.com - Clinical Procedures for Safer Patient Care. Doyle. Chapter 5.8 Oral Suctioning. https://opentextbc.ca clinical skills/chapter 5-7 oral suctioning - Subglottic secretion suction for preventing ventilator-associated pneumonia: an updated meta-analysis and trial sequential analysis; Zhi Mao1†, Ling Gao2†, Guoqi Wang3†, Chao Liu1, Yan Zhao1, Wanjie Gu4, Hongjun Kang1 and Feihu Zhou

57. Oral Care What is it Key industry players Who does it? RT vs nursing vs shared How often? Q2 vs Q4 Is deep oropharyngeal suctioning the same as subglottic?

58. Oral Care – Deep Oropharyngeal Suction ETT Cuff Catheter tip

59. Literature Review “Aspiration of Fluid Above the Endotracheal Tube Cuff: A comparison of Two Methods ” Critical Care Medicine, Branson et al. Dec 2016 V ol 44 No 12 Study Purpose Determine % success of placement at the cuff of a standard oral suction catheter Determine amount of fluid above the cuff removed with a standard suction catheter “Aspiration of Fluid Above the Endotracheal Tube Cuff: A comparison of Two Methods ” Critical Care Medicine, Branson et al. Dec 2016 Vol 44 No 12

60. Results Critical Care Medicine, Branson et al. Dec 2016 Vol 44 No 12 N= 22 care providers Standard oral catheter 0% success, placement at the cuff 0mL removed from above the cuff “Aspiration of Fluid Above the Endotracheal Tube Cuff: A comparison of Two Methods ” Critical Care Medicine , Branson et al. Dec 2016 Vol 44 No 12

61. Patient Response to Suctioning Discussion Patient Response Oral Deep Oral Closed Suction in-line (Open)

62. What is the Tri-Flo™ Subglottic Suction System?

63. Tri-Flo™ Subglottic Suction System Technique to achieve subglottic suctioning for ventilated patients in the ICU regardless of ETT type.

64. Device Overview Suction Guide 14 Fr Suction Line Securement Clip

65. For Internal use Only 65

66. With Tri-Flo System Tri-Flo Subglottic Suction System Without Tri-Flo System

67. Literature Review “Aspiration of Fluid Above the Endotracheal Tube Cuff: A comparison of Two Methods ” Critical Care Medicine, Branson et al. Dec 2016 V ol 44 No 12 Study Purpose Determine % success of placement at the cuff of a standard oral suction catheter vs the Tri-Flo (Sherpa) Suction System Determine amount of fluid above the cuff removed with a standard suction catheter vs the Tri-Flo (Sherpa) Suction System “Aspiration of Fluid Above the Endotracheal Tube Cuff: A comparison of Two Methods ” Critical Care Medicine , Branson et al. Dec 2016 Vol 44 No 12

68. Results Critical Care Medicine, Branson et al. Dec 2016 Vol 44 No 12 N= 22 care providers Standard oral catheter 0% success, placement at the cuff 0mL removed from above the cuff Tri-Flo Suction System 100% success, placement at the cuff 6.2mL +/- 0.8mL out of 7mL removed from above the cuff “Aspiration of Fluid Above the Endotracheal Tube Cuff: A comparison of Two Methods ” Critical Care Medicine , Branson et al. Dec 2016 Vol 44 No 12

69. Common Potential Objections Objection Talking Point Demonstration Will catheter puncture ETT cuff? Engineering testing shows advancement 90 times to the ETT cuff (inflated to 30 cmH 2 O) does not lead to cuff puncture. K8 Show deflection of catheter tip when advanced into your palm or table Patient reaction - gag reflex, increased blood pressure, accelerated heart rate Share clinical feedback to date – patient response variable but similar to inline or deep oral suctioning Damage vocal cords? Refer to abstract published in ESICM journal showing in 13 pigs ventilated for 72 hours, no difference in patients with ETT vs patients with ETT + AirLife Subglottic K9 Show an ETT for comparison which is always inserted through the vocal cords and contrast with the size/flexibility of our suction catheter What if the catheter clogs? Refer to catheter design features - 14 Fr size and 3 ports at distal tip Discuss possibility to replace line if clogging persists Show catheter tip with 3 ports Blind procedure - how do we know we are in the right place? Discuss proper alignment of guide, tactile feedback at cuff and measurement markings on the suction catheter Show care provider how the measurement markings on the suction catheter can be used relative to the ETT markings

70. ETT & Catheter Marking Alignment

71. Cost Avoidance Calculator ROI

72. Non Subglottic ETT Users Why Do Something? Why Now? What is the motivation? What is the cost, risk, or personal impact to not changing current practices? Why Vyaire Tri-Flo Subglottic Suction System? GOAL: Improve Patient Care and Outcomes

73. Why Do Something? Increased patient safety Data indicates the importance of proper oral care and tracheal care (mid trachea and lower subglottic trachea-below the vocal cords) Presence of subglottic secretions presents higher risks of aspiration Both Oral and Subglottic secretion suction/removal is recommended as standard of care by ATS, AACN, APIC, CDC and IDSA Micro-aspirations put patient at risk for HAI’s Implementing recommended guidelines for secretion management helps reduce risks of micro-aspiration Reduction in length of ventilator days Reduce costs of care Safety Performance - Am J Respir Crit Care Med Vol 171. pp388-416, 2005. - https ://www.aacn.org/clinical-resources/practice-alerts/ventilator-associated-pneumonia-vap - Infect Control Hosp Epidemilogy 2014;35(8): 915-936 - Aspiration Syndromes Clinical Presentation: History, Physical, Causes emedicine.medscape.com/article/1005303 - Silent aspiration: what do we know? – NCBI https://www.ncbi.nlm.nih.gov/pubmed/16362510 - How to avoid Microaspiration? BMC Infectious Diseases201414:119; DOI: 10.1186/1471-2334-14-119;  Blot et al.; licensee BioMed Central Ltd. 2014

74. Why Now? Non SG ETT users Deep oral care is not the same as above the cuff suctioning, and does not get to the secretions pooling around the cuff Deep Oral care just manages secretions in the oral cavity Early adoption of subglottic suctioning and alignment with industry practice guidelines increases standardization in care Minimizes patient risks for micro-aspirations Costs associated with deviation from standard practice of care: Improved secretion management above the cuff can minimize ICU LOS by 1.5 days and Duration of ventilator days by 1 day on average Reduction in use of antibiotics Cost of MV =$150 0/day Total cost = $2500-4000 / day Increased cost per patient > $ 40,000 Safety Performance - How to avoid Microaspiration? BMC Infectious Diseases201414:119; DOI: 10.1186/1471-2334-14-119;  Blot et al.; licensee BioMed Central Ltd. 2014 - “ Subglottic Secretion Drainage for Preventing Ventilator Associated Pneumonia: A systematic review and meta-analysis” Crit Care Med, J Muscedere 2011 - Crit Care Med. 2008 Mar;36(3):724-30. doi: 10.1097/CCM.0B013E31816536F7. Prolonged acute mechanical ventilation, hospital resource utilization, and mortality in the United States - “ Cost Effectiveness in the Intensive Care Unit”, Rochelle A. Dicker, MD, Associate Professor of Surgery and Anesthesia, UCSF Critical Care Medicine and Trauma Conference 2013.

75. Why Tri-Flo SGS System - non SG ETT users? Safety Performance AirLife Subglottic Suction helps gets more secretions than current practices (standard catheters) due to easier placement! ( Branson Study) Deep oral suctioning does not get to the cuff Guideline recommend combination of oral care and subglottic suctioning at the cuff Minimize the risk of clinicians not performing deep oral care as it is a “blind” procedure Placement of SGS system is guided on the anterior side of airway; helps minimize potential of trauma to vocal cords Minimize blind probing reduces risk of gagging and tissue trauma - Https :// en.wikipedia.org/wiki - “ Aspiration of Fluid Above the Endotracheal Tube Cuff: A comparison of Two Methods” Critical Care Medicine, Branson et al. Dec 2016 Vol 44 No 12 - Am J Respir Crit Care Med Vol 171. pp388-416, 2005. - https ://www.aacn.org/clinical-resources/practice-alerts/ventilator-associated-pneumonia-vap - Infect Control Hosp Epidemilogy 2014;35(8): 915-936 - An Apic Guide; 2009; Guide to the Elimination of Ventilator-Associated Pneumonia