Title: Length of use guidelines for oxygen tubing and face mask equipment Date: September 12, 2007 Context and policy issues: There is concern that oxygen tubing and face mask equipment in the ventilator circuit and humidifier may be the source of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. However, collective evidence suggests that the origin of VAP is more likely from sources other than the ventilator circuit. 1,2 The frequency of ventilator circuit changes varies greatly between hospitals and health care services. 3 There may be a direct cost burden associated with more frequent ventilator circuit changes. There is a need to know the recommendations from existing guidelines for change frequency of the ventilator circuit including oxygen face masks and tubing to make an informed decision about how often these devices should be changed. Research questions: What are the guidelines for length of use for continuous and intermittent usage of oxygen tubing and face masks for patients who reside in long-term care facilities or home care and require oxygen delivery or medication delivery via nebulizer? Methods: A literature search was conducted on key health technology assessment resources, including PubMed, The Cochrane Library (Issue 2, 2007), University of York Centre for Reviews and Dissemination (CRD) databases, ECRI s HTAIS, EuroScan, international HTA agencies, and a focused Internet search. Results include English language publications from 2002 to date. Disclaimer: The Health Technology Inquiry Service (HTIS) is an information service for those involved in planning and providing health care in Canada. HTIS responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources and a summary of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. HTIS responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report. Copyright: This report contains CADTH copyright material. It may be copied and used for non-commercial purposes, provided that attribution is given to CADTH. Links: This report may contain links to other information on available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners own terms and conditions.
Summary of findings: From the limited literature search, we identified one guideline from the Canadian Critical Care Society, seven guidelines from the American Association for Respiratory Care (AARC), and one from the American Medical Association (AMA). The recommendations related to the frequency of change of the ventilator circuit including masks and tubing are summarized in Table 1. Table 1: summary of guidelines on changing ventilator circuits Guideline Title and methods Recommendations Canadian Critical Care Society Evidence-Based Practice Guidelines (2004) 4 Evidence-Based Clinical Practice Guideline for Prevention of Ventilator- Associated Pneumonia AARC Evidence-Based Guidelines (2003) 3 Guidelines (2004) 5 A systematic review was conducted on trials and systematic reviews. The evidence was synthesized and graded by panel members. The population consisted of adult patients cared for in the ICU and the target audience was ICU clinicians. Care of the ventilator circuit and its relation to ventricular-associated pneumonia A systematic review was conducted on trials and observational studies. The strength of the evidence was graded from A to D (A: highest quality; D: expert opinion) Application of Continuous Positive Airway Pressure to Neonates Via Nasal Prongs, or Nasopharyngeal Tube, or Nasal Mask 2004 Revision & Update Changes of ventilator circuits should be done only for each new patient and if the circuits are soiled. For frequency of ventilator circuit changes: No scheduled changes For frequency of humidifier changes: Recommend weekly changes of heat and moisture exchangers Ventilator circuit should not be changed routinely for infection control purposes. The available evidence suggests no patient harm and considerable cost savings associated with extended ventilator circuit change intervals. The maximum duration of time that circuits can be used safely is unknown (Grade A). No special precautions are necessary, but Standard Precautions as described by the Centers for Disease Control (CDC) 6 should be employed. Disposable nasal CPAP kits are recommended and are intended for single-patient use. Routine disposable circuit changes are unnecessary for infection control purposes when the humidifying device is other than an aerosol Oxygen tubing and face mask equipment 2
Guidelines (2007) 7 Guidelines (2003) 9 Guidelines (2002) 10 Guidelines (2007) 11 Long-Term Invasive Mechanical Ventilation in the Home 2007 Revision & Update Intermittent Positive Pressure Breathing 2003 Revision & Update Oxygen Therapy for Adults in the Acute Care Facility 2002 Revision & Update Oxygen Therapy in the Home or Alternate Site Health Care Facility 2007 Revision & Update generator. Evidence is lacking to support an optimal plan for changing and processing ventilator circuits and ancillary equipment in the home. The standard of care in the home is that ventilator circuits need not be changed more often than once each week. However, CDC guidelines 8 and studies from institutional settings suggest that ventilator circuits need only be changed when visibly soiled Nebulizers/ Intermittent positive pressure breathing circuits should be changed between patients, when visibly soiled, or according to institutional infection control policy. Under normal circumstances, low-flow oxygen systems (including cannulas and simple masks) do not present clinically important risk of infection and need not be routinely replaced. High-flow systems that employ heated humidifiers and aerosol generators, particularly when applied to patients with artificial airways, can pose important risk of infection. In the absence of definitive studies to support change-out intervals, results of institution-specific and patient-specific surveillance measures should dictate the frequency with which such equipment is replaced. Under normal circumstances low-flow oxygen systems without humidifiers do not present a clinically important risk of infection and need not be routinely replaced. High-flow systems that employ heated humidifiers and aerosol generators, particularly when applied to patients with artificial airways, can be important sources of infection and should be cleaned and disinfected on a regular basis, although there are no definitive studies regarding the frequency of tube changes at home or in long-term care facilities. Oxygen tubing and face mask equipment 3
Guidelines (2002) 12 AMA Practical Guidelines for Clinicians (2006) 13 Selection of an Oxygen Delivery Device for Neonatal and Pediatric Patients 2002 Revision & Update Preventing Ventilator- Associated Pneumonia: An evidence-based Approach of Modifiable Risks Factors Evidence collected from literature review Low flow systems: Under normal circumstances, lowflow oxygen systems do not present clinically important risk of infection and do not require routine replacement on the same patient. Nasopharyngeal catheters should be changed every 24 hours. Transtracheal catheters should be changed every 3 months. High flow systems: Large-volume nebulizers should be changed every 24 hours when applied to patients with an artificial airway. In the absence of definitive studies to support change-out intervals on nonintubated patients, results of institution-specific and patientspecific surveillance measures should dictate the frequency with which such equipment is replaced. Current recommendations are to change ventilator circuits based on visual contamination of the circuit with blood, emesis, or purulent secretions as opposed to routine circuit changes based on duration Conclusions and implications for decision or policy making: Under normal circumstances, ventilator circuits including face masks and tubing should not be changed routinely for infection control purposes. However, the maximum duration of use of the circuit was unknown. Change of ventilator circuits should be done between patients and be based on visual contaminations. Care should be adhered to universal precautions and infection control guidelines posted for specific patients. Sterile and disinfecting procedures of any reusable equipment between patients should be strictly adhered to manufacturer s recommendations. Prepared by: Khai Tran, MSc, PhD, Research Officer Monika Mierzwinski-Urban, MLIS, Information Specialist Health Technology Inquiry Service (HTIS) E-mail: HTIS@cadth.ca Toll free phone: 1-866-898-8439 Oxygen tubing and face mask equipment 4
References 1. Cook D, De JB, Brochard L, Brun-Buisson C. Influence of airway management on ventilator-associated pneumonia: evidence from randomized trials. JAMA 1998;279(10):781-7. 2. Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 1998;129(6):433-40. 3. Hess DR, Kallstrom TJ, Mottram CD, Myers TR, Sorenson HM, Vines DL. Care of the ventilator circuit and its relation to ventilator-associated pneumonia. Respir Care 2003;48(9):869-79. Available: http://www.rcjournal.com/contents/09.03/09.03.0869.pdf (accessed 2007 Aug 22). 4. Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004;141(4):305-13. Available: http://www.annals.org/cgi/reprint/141/4/305.pdf (accessed 2007 Aug 24). 5. AARC Clinical Practice Guideline: application of continuous positive airway pressure to neonates via nasal prongs, nasopharyngeal tube, or nasal mask--2004 revision & update. Respir Care 2004;49(9):1100-8. Available: http://www.rcjournal.com/cpgs/pdf/09.04.1100.pdf (accessed 2007 Aug 22). 6. Siegel JD, Rhinehart E, Jackson M, Chiarello L, the Healthcare Infection Control Practices Advisory Committee. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. Atlanta (GA): Center for Disease Control and Prevention; 2007. Available: http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/hicpacisolation2007.pdf (accessed 2007 Sep 5). 7. AARC Clinical Practice Guideline: long-term invasive mechanical ventilation in the home- 2007 revision & update. Respir Care 2007;52(1):1056-62. Available: http://www.rcjournal.com/contents/08.07/08.07.1056.pdf (accessed 2007 Aug 22). 8. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. Atlanta (GA): Center for Disease Control and Prevention; 2004. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm (accessed 2007 Sep 5). 9. AARC Clinical Practice Guideline: intermittent positive pressure breathing--2003 revision & update. Respir Care 2003;48(5):540-6. Available: http://www.rcjournal.com/contents/05.03/05.03.0540.pdf (accessed 2007 Aug 22). 10. Kallstrom TJ. AARC Clinical Practice Guideline: oxygen therapy for adults in the acute care facility--2002 revision & update. Respir Care 2002;47(6):717-20. Oxygen tubing and face mask equipment 5
11. AARC Clinical Practice Guideline: oxygen therapy in the home or alternate site health care facility--2007 revision & update. Respir Care 7 A.D.;52(1):1063-8. 12. Myers TR. AARC Clinical Practice Guideline: selection of an oxygen delivery device for neonatal and pediatric patients--2002 revision & update. Respir Care 2002;47(6):707-16. 13. Isakow W, Kollef MH. Preventing ventilator-associated pneumonia: an evidence-based approach of modifiable risk factors. Semin Respir Crit Care Med 2006;27(1):5-17. Oxygen tubing and face mask equipment 6