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Sanaie S, Rahnemayan S, Azizi S, Saghaleini SH, Ghamari AA, Ghojazadeh M, Mahmoodpoor A. Comparison of subglottic vs. non-subglottic secretion drainage in prevention of Ventilator Associated Pneumonia: A systematic review and meta-analysis. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weston Smith N, Spivey M. Promoting subglottic secretion drainage: a quality improvement project in a UK critical care unit. BMJ Open Qual 2021; 10:bmjoq-2020-001269. [PMID: 34039618 PMCID: PMC8160166 DOI: 10.1136/bmjoq-2020-001269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/18/2021] [Indexed: 11/04/2022] Open
Abstract
The aim of the study was to promote the practice of subglottic secretion drainage (SSD) in a UK critical care unit. SSD is a technique employed to reduce microaspiration of oropharyngeal secretions in patients with cuffed endotracheal airways. Aspiration of oropharyngeal secretions is the accepted cause of the majority of ventilator-associated pneumonia (VAP), a complication of invasive ventilation with high associated mortality. The plan–do–study–act methodology was employed. The local critical care patient database was searched for patients requiring mechanical ventilation via a tracheostomy tube with subglottic port in the 3 months prior to intervention. Patient records were interrogated for evidence of the practice of SSD. The intervention involved the introduction of a tracheostomy care bundle to be prescribed on insertion of a tracheostomy on the critical care unit, in combination with departmental teaching. The bundle included prompts for nursing staff to practise regular SSD and to complete a tracheostomy care plan at the end of shift. A total of 24 patients were included. A review of practice was conducted every 3 months for 1 year. This showed an improvement in documented evidence of SSD from 0% of days at baseline to 85.7% of days at 1 year. Implementation of a tracheostomy order set prescribing regular SSD resulted in an improvement in the practice of SSD in patients ventilated via tracheostomy. This has implications for patient outcomes and healthcare costs, given that SSD has been shown to reduce incidence of VAP.
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Affiliation(s)
| | - Michael Spivey
- Department of Critical Care, Royal Cornwall Hospitals NHS Trust, Truro, UK
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Pozuelo-Carrascosa DP, Herráiz-Adillo Á, Alvarez-Bueno C, Añón JM, Martínez-Vizcaíno V, Cavero-Redondo I. Subglottic secretion drainage for preventing ventilator-associated pneumonia: an overview of systematic reviews and an updated meta-analysis. Eur Respir Rev 2020; 29:29/155/190107. [PMID: 32051169 PMCID: PMC9488747 DOI: 10.1183/16000617.0107-2019] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/21/2019] [Indexed: 12/18/2022] Open
Abstract
Although several guidelines recommend subglottic secretion drainage as a strategy for prevention of ventilator-associated pneumonia (VAP), its use is not widespread. With the aim to assess the effectiveness of subglottic secretion drainage for preventing VAP and to improve other outcomes such as mortality, duration of mechanical ventilation and length of stay in the intensive care unit (ICU) or hospital, an electronic search of the Cochrane Library, MEDLINE, Web of Science and Embase was undertaken. Nine systematic reviews with meta-analysis (in the overview of reviews) and 20 randomised controlled trials (in the updated meta-analysis) were included. In the overview of reviews, all systematic reviews with meta-analysis included found a positive effect of subglottic secretion drainage in the reduction of incidence of VAP. In the updated meta-analysis, subglottic secretion drainage significantly reduced VAP incidence (risk ratio (RR) 0.56, 95% CI 0.48–0.63; I2=0%, p=0.841) and mortality (RR 0.88, 95% CI 0.80–0.97; I2=0%, p=0.888). This is the first study that has found a decrease of mortality associated with the use of subglottic secretion drainage. In addition, subglottic secretion drainage is an effective measure to reduce VAP incidence, despite not improving the duration of mechanical ventilation and ICU and/or hospital length of stay. Subglottic secretion drainage is an effective measure to reduce mortality and VAP incidence, despite not improving the duration of mechanical ventilation or length of stay in ICU and/or hospital.http://bit.ly/2PeJLR1
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Affiliation(s)
- Diana P Pozuelo-Carrascosa
- Health and Social Care Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain.,Faculty of Physiotherapy and Nursing, Universidad de Castilla-La Mancha, Toledo, Spain
| | - Ángel Herráiz-Adillo
- Dept of Primary Care, Health Service of Castilla-La Mancha (SESCAM), Tragacete, Cuenca, Spain
| | - Celia Alvarez-Bueno
- Health and Social Care Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
| | - Jose Manuel Añón
- Intensive Care Unit, Hospital Universitario La Paz-Carlos III, IdiPAZ, CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España
| | - Vicente Martínez-Vizcaíno
- Health and Social Care Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain.,Universidad Autónoma de Chile, Faculty of Health Sciences, Madrid, Spain
| | - Iván Cavero-Redondo
- Health and Social Care Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
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Hyzy RC, McSparron J. Ventilator-Associated Pneumonia. EVIDENCE-BASED CRITICAL CARE 2020. [PMCID: PMC7120513 DOI: 10.1007/978-3-030-26710-0_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ventilator-associated pneumonia occurs in patients who have been intubated for at least 2–3 days with significant exposure to hospital-acquired organisms. Treatment should be initiated rapidly and cover Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumonia, and methicillin-resistant Staphylococcus aureus(MRSA). Within 72 h or with the availability of culture results, antibiotics should be narrowed. Active research is on-going to identify patients at risk for ventilator-associated complications and to minimize the likelihood of infection in these patients.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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Rouzé A, Martin-Loeches I, Nseir S. Airway Devices in Ventilator-Associated Pneumonia Pathogenesis and Prevention. Clin Chest Med 2019; 39:775-783. [PMID: 30390748 DOI: 10.1016/j.ccm.2018.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Airway devices play a major role in the pathogenesis of microaspiration of contaminated oropharyngeal and gastric secretions, tracheobronchial colonization, and ventilator-associated pneumonia (VAP) occurrence. Subglottic secretion drainage is an effective measure for VAP prevention, and no routine change of ventilator circuit. Continuous control of cuff pressure, silver-coated tracheal tubes, low-volume low-pressure tracheal tubes, and the mucus shaver are promising devices that should be further evaluated by large randomized controlled trials. Polyurethane-cuffed, conical-shaped cuff, and closed tracheal suctioning system are not effective and should not be used for VAP prevention.
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Affiliation(s)
- Anahita Rouzé
- CHU Lille, Critical Care Center, bd du Pr Leclercq, Lille F-59000, France
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Trinity College, Welcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin 94568, Ireland
| | - Saad Nseir
- CHU Lille, Critical Care Center, bd du Pr Leclercq, Lille F-59000, France; Lille University, Medicine School, 1 Place de Verdun, Lille F-59000, France.
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Lacherade JC, Azais MA, Pouplet C, Colin G. Subglottic secretion drainage for ventilator-associated pneumonia prevention: an underused efficient measure. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:422. [PMID: 30581830 DOI: 10.21037/atm.2018.10.40] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Subglottic secretion drainage (SSD) is one of the recommended strategies to prevent ventilator-associated pneumonia (VAP) with a high level of evidence, especially regarding early-onset pneumonia. All meta-analysis found that the use of SSD reduces VAP occurrence with a relative risk (RR) reduction of 45%. In some of them, SSD reduces the duration of mechanical ventilation (MV) but without beneficial effect on intensive care unit (ICU) or hospital mortality. In spite of the edited recommendations, SSD has not been widely implemented in ICUs and remains underused. Several factors could account for this: doubts on the innocuousness of using SSD, persisting reservations on the SSD effect on other outcomes than VAP, a high variability in the volume of secretions suctioned between patients and, for each individual patient, during the period of MV and the initial increased expense of the specific endotracheal tubes (ETs) allowing SSD which limits the availability of these devices.
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Affiliation(s)
- Jean-Claude Lacherade
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
| | - Marie-Ange Azais
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
| | - Caroline Pouplet
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
| | - Gwenhael Colin
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
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Huang XA, Du YP, Fu BB, Li LX. Influence of subglottic secretion drainage on the microorganisms of ventilator associated pneumonia: A meta-analysis for subglottic secretion drainage. Medicine (Baltimore) 2018; 97:e11223. [PMID: 29995754 PMCID: PMC6076059 DOI: 10.1097/md.0000000000011223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The influence of the subglottic secretion drainage (SSD) on the microorganisms of ventilator associated pneumonia (VAP) is still unclear.A meta-analysis focusing on the influence of the SSD on the microorganisms of VAP. METHODS A comprehensive search was conducted through the online studies of PubMed, Embase, Cochrane Library, Google scholar, CNKI (China National Knowledge Infrastructure), and VIPI (Database for Chinese Technical Periodicals) using specific search terms.Included studies were randomized controlled trials (RCTs) that compare the microorganisms of VAP between SSD and standard endotracheal tube care in mechanically ventilated adults. RESULTS Nine RCTs were eligible. There was no significant difference in the rate of VAP caused by nonfermentative bacteria and enterobacteria between SSD group and control group (OR = 0.73, 95%CI, 0.53-1.01; P = .06). The episodes of VAP caused by Gram-positive cocci and Haemophilus influenzae organisms were lower in the SSD group (OR = 0.29, 95%CI, 0.18-0.48; P<0.00001). Less mean volume of SSD daily was observed in VAP group (OR = -16.97, 95%CI, -29.87-4.08; P = .010). CONCLUSION We found SSD to be associated with significant decreases in VAP caused by Gram-positive cocci and H influenzae organisms but no significant differences in VAP caused by nonfermentative bacteria and enterobacteria. Less mean volume of SSD daily was observed in VAP group.
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Affiliation(s)
| | - Yan Ping Du
- Department of Respiratory Medicine, Zhongshan Hospital Xiamen University, Teaching Hospital of Fujian Medical University
| | | | - Liu Xia Li
- Fujian Medical University, Union Hospital, Zhongshan Hospital Xiamen University
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Ventilator-Associated Pneumonia and Other Complications. EVIDENCE-BASED CRITICAL CARE 2017. [PMCID: PMC7120823 DOI: 10.1007/978-3-319-43341-7_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ventilator-associated pneumonia occurs in patients who have been intubated for two to three days with significant exposure to hospital-acquired organisms. Treatment should be initiated rapidly and cover P. aeruginosa, Escheriochia coli, Klebsiella pneumonia, and Acinetobacter species as well as methicillin-resistant S. aureus. Within 72 h or with the availability of culture results, antibiotics should be narrowed. Active research is on-going to identify patients at risk for ventilator-associated complications and to minimize the likelihood of infection in these patients.
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Abstract
Mechanical ventilator use is fraught with risk of complications. Ventilator-associated pneumonia (VAP) is a common complication that prolongs stays on the ventilator and increases mortality and costs. The Centers for Disease Control and Prevention recommend the use of the term, ventilator-associated event. Prevention and/or interruption of cycle of inflammation, colonization of respiratory tract, and ventilator-associated tracheobronchitis are key to managing VAP. Modifying risk factors using a ventilator bundle is considered standard of care. The contentious factors and the lack of support for early tracheotomy, parenteral nutrition, and monitoring of gastric residuals are also addressed. Finally, the role of ventilator-associated tracheobronchitis in VAP is discussed.
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Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 2016; 35:915-36. [DOI: 10.1086/677144] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2015; 35 Suppl 2:S133-54. [PMID: 25376073 DOI: 10.1017/s0899823x00193894] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Drainage des sécrétions sous-glottiques et pneumonies acquises sous ventilation mécanique. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0677-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Weavind LM, Saied N, Hall JD, Pandharipande PP. Care Bundles in the Adult ICU: Is It Evidence-Based Medicine? CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0017-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Oostdijk EAN, de Wit GA, Bakker M, de Smet AMGA, Bonten MJM. Selective decontamination of the digestive tract and selective oropharyngeal decontamination in intensive care unit patients: a cost-effectiveness analysis. BMJ Open 2013; 3:bmjopen-2012-002529. [PMID: 23468472 PMCID: PMC3612803 DOI: 10.1136/bmjopen-2012-002529] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To determine costs and effects of selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) as compared with standard care (ie, no SDD/SOD (SC)) from a healthcare perspective in Dutch Intensive Care Units (ICUs). DESIGN A post hoc analysis of a previously performed cluster-randomised trial (NEJM 2009;360:20). SETTING 13 Dutch ICUs. PARTICIPANTS Patients with ICU-stay of >48 h that received SDD (n=2045), SOD (n=1904) or SC (n=1990). INTERVENTIONS SDD or SOD. PRIMARY AND SECONDARY OUTCOME MEASURES Effects were based on hospital survival, expressed as crude Life Years Gained (cLYG). The incremental cost-effectiveness ratio (ICER) was calculated, with corresponding cost acceptability curves. Sensitivity analyses were performed for discount rates, costs of SDD, SOD and mechanical ventilation. RESULTS Total costs per patient were €41 941 for SC (95% CI €40 184 to €43 698), €40 433 for SOD (95% CI €38 838 to €42 029) and €41 183 for SOD (95% CI €39 408 to €42 958). SOD and SDD resulted in crude LYG of +0.04 and +0.25, respectively, as compared with SC, implying that both SDD and SOD are dominant (ie, cheaper and more beneficial) over SC. In cost-effectiveness acceptability curves probabilities for cost-effectiveness, compared with standard care, ranged from 89% to 93% for SOD and from 63% to 72% for SDD, for acceptable costs for 1 LYG ranging from €0 to €20 000. Sensitivity analysis for mechanical ventilation and discount rates did not change interpretation. Yet, if costs of the topical component of SDD and SOD would increase 40-fold to €400/day and €40/day (maximum values based on free market prices in 2012), the estimated ICER as compared with SC for SDD would be €21 590 per LYG. SOD would remain cost-saving. CONCLUSIONS SDD and SOD were both effective and cost-saving in Dutch ICUs.
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Affiliation(s)
- Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Williams TA. Is the evidence for the use of subglottic drainage to prevent ventilated-associated pneumonia sufficient to change practice? Aust Crit Care 2012; 25:200-4. [PMID: 22484207 DOI: 10.1016/j.aucc.2012.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 03/06/2012] [Indexed: 12/29/2022] Open
Abstract
This paper critiques the systematic review and meta-analysis of the effect of subglottic drainage among patients who received mechanical ventilation. Subglottic secretion drainage can reduce bacterial pathogens from entering the lower respiratory tract and potentially reduce the occurrence of ventilator-associated pneumonia. A summary of the systematic review and meta-analysis is provided. The critique examines the study's strengths and weaknesses and implications for practice are discussed. It is a well-conducted systematic review and meta-analysis with few suggestions for improvement. Subglottic secretion drainage reduced the incidence of ventilator-associated pneumonia. Several studies have shown positive effects of using subglottic drainage but despite the evidence, the practice in ICUs is not widespread.
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