Pulmonary Toilet

Suction

Closed and open suction had the same VAP outcomes and costs (Intens Care Med 2006;32:538)

Metaanalysis Inten Care Med 2006;32:1329

Another MA of closed/open Crit Care Med 2007;35(1):260

Chest Physiotherapy

Pulmonary Medications

1. Factors that influence the efficacy of aerosol delivery in the mechanically ventilated patient include33:
   1. Position of administration in the circuit: the MDI should be closer to the endotracheal tube at the Y-piece with a chamber, compared with a pneumatic nebulizer, which should be at least 30 cm from the Y-piece. (Study)
   2. Humidification: this can decrease aerosol delivery to the respiratory tract because of greater deposition in the ventilator circuit. Higher doses may be required to achieve the desired effect.
   3. Timing of delivery: the aerosol should be delivered during the inspiratory phase to maximize drug delivery.
   4. Flow rates: slower inspiratory flow rates (and therefore longer inspiratory time) increase delivery of nebulized medications. A decelerating flow pattern can also increase delivery to the lower airways.
   5. Tidal volumes: larger tidal volumes greater than 500 mL ensure optimal delivery.
   6. Endotracheal tube size: tube sizes less than 7.0 mm reduce delivery.
   7. Density of inhaled gas: low-density gases such as helium-oxygen mixtures increase deposition to the lower airways by increasing laminar flow and producing smaller respirable particle size. (Critcaretextonline.com)

Curr Opin Crit Care 2007;13:27 review of inhalation therapy in vent pts

nebulizers may increase the rate of vap (Crit Care Med 2011;39:725)

How to use MDIs with the Vent

That is a 60 ml syringe; thread it into one of the ports or better yet, place an IV cath through the vent tubing and attach a medlock, tape it down.