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Howroyd F, Chacko C, MacDuff A, Gautam N, Pouchet B, Tunnicliffe B, Weblin J, Gao-Smith F, Ahmed Z, Duggal NA, Veenith T. Ventilator-associated pneumonia: pathobiological heterogeneity and diagnostic challenges. Nat Commun 2024; 15:6447. [PMID: 39085269 PMCID: PMC11291905 DOI: 10.1038/s41467-024-50805-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024] Open
Abstract
Ventilator-associated pneumonia (VAP) affects up to 20% of critically ill patients and induces significant antibiotic prescription pressure, accounting for half of all antibiotic use in the ICU. VAP significantly increases hospital length of stay and healthcare costs yet is also associated with long-term morbidity and mortality. The diagnosis of VAP continues to present challenges and pitfalls for the currently available clinical, radiological and microbiological diagnostic armamentarium. Biomarkers and artificial intelligence offer an innovative potential direction for ongoing future research. In this Review, we summarise the pathobiological heterogeneity and diagnostic challenges associated with VAP.
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Affiliation(s)
- Fiona Howroyd
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK.
- Institute of Inflammation and Ageing, The University of Birmingham, Edgbaston, Birmingham, UK.
| | - Cyril Chacko
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
- Institute of Acute Care, Royal Wolverhampton Hospital and University of Wolverhampton, Wolverhampton, UK
| | - Andrew MacDuff
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
- Institute of Acute Care, Royal Wolverhampton Hospital and University of Wolverhampton, Wolverhampton, UK
| | - Nandan Gautam
- Critical Care Department, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK
| | - Brian Pouchet
- Critical Care Department, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK
| | - Bill Tunnicliffe
- Critical Care Department, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK
| | - Jonathan Weblin
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK
| | - Fang Gao-Smith
- Institute of Inflammation and Ageing, The University of Birmingham, Edgbaston, Birmingham, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, The University of Birmingham, Edgbaston, Birmingham, UK.
| | - Niharika A Duggal
- Institute of Inflammation and Ageing, The University of Birmingham, Edgbaston, Birmingham, UK.
| | - Tonny Veenith
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Trust, Wolverhampton, UK.
- Institute of Acute Care, Royal Wolverhampton Hospital and University of Wolverhampton, Wolverhampton, UK.
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Pérez-Granda MJ, Alonso B, Zavala R, Latorre MC, Hortal J, Samaniego R, Bouza E, Muñoz P, Guembe M. Selective digestive decontamination solution used as "lock therapy" prevents and eradicates bacterial biofilm in an in vitro bench-top model. Ann Clin Microbiol Antimicrob 2020; 19:44. [PMID: 32972419 PMCID: PMC7513905 DOI: 10.1186/s12941-020-00387-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023] Open
Abstract
Background Most preventing measures for reducing ventilator-associated pneumonia (VAP) are based mainly on the decolonization of the internal surface of the endotracheal tubes (ETTs). However, it has been demonstrated that bacterial biofilm can also be formed on the external surface of ETTs. Our objective was to test in vitro the efficacy of selective digestive decontamination solution (SDDs) onto ETT to prevent biofilm formation and eradicate preformed biofilms of three different microorganisms of VAP. Methods We used an in vitro model in which we applied, at the subglottic space of ETT, biofilms of either P. aeruginosa ATCC 15442, or E. coli ATCC 25922, or S. aureus ATCC 29213, and the SDDs at the same time (prophylaxis) or after 72 h of biofilm forming (treatment). ETT were incubated during 5 days with a regimen of 2 h-locks. ETT fragments were analyzed by sonication and confocal laser scanning microscopy to calculate the percentage reduction of cfu and viable cells, respectively. Results Median (IQR) percentage reduction of live cells and cfu/ml counts after treatment were, respectively, 53.2% (39.4%—64.1%) and 100% (100%–100.0%) for P. aeruginosa, and 67.9% (46.7%–78.7%) and 100% (100%–100.0%) for E. coli. S. aureus presented a complete eradication by both methods. After prophylaxis, there were absence of live cells and cfu/ml counts for all microorganisms. Conclusions SDDs used as “lock therapy” in the subglottic space is a promising prophylactic approach that could be used in combination with the oro-digestive decontamination procedure in the prevention of VAP.
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Affiliation(s)
- María Jesús Pérez-Granda
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain.,CIBER Enfermedades Respiratorias-CIBERES, CB06/06/0058), Madrid, Spain
| | - Beatriz Alonso
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain. .,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain. .,Servicio de Microbiología Clínica y Enfermedades Infecciosas, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario "Gregorio Marañón", C/. Dr. Esquerdo, 46, Madrid, 28007, Spain.
| | - Ricardo Zavala
- Biology Department, School of Biology, Universidad Complutense de Madrid, Madrid, 28040, Spain
| | - María Consuelo Latorre
- Biology Department, School of Biology, Universidad Complutense de Madrid, Madrid, 28040, Spain
| | - Javier Hortal
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain.,CIBER Enfermedades Respiratorias-CIBERES, CB06/06/0058), Madrid, Spain
| | - Rafael Samaniego
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain.,Confocal Laser Scanning Microscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain
| | - Emilio Bouza
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, 28040, Spain
| | - Patricia Muñoz
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain.,CIBER Enfermedades Respiratorias-CIBERES, CB06/06/0058), Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, 28040, Spain
| | - María Guembe
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain. .,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain. .,Servicio de Microbiología Clínica y Enfermedades Infecciosas, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario "Gregorio Marañón", C/. Dr. Esquerdo, 46, Madrid, 28007, Spain.
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3
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Nazari R, Boyle C, Panjoo M, Salehpour-Omran M, Nia HS, Yaghoobzadeh A. The Changes of Endotracheal Tube Cuff Pressure during Manual and Intermittent Controlling in Intensive Care Units. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2020; 25:71-75. [PMID: 31956601 PMCID: PMC6952914 DOI: 10.4103/ijnmr.ijnmr_55_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 11/02/2019] [Accepted: 11/11/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Usually, the endotracheal tube cuff pressure is controlled by cuff pressure monitoring. However, the intermittent pilot-manometer connection and disconnection may cause a change in the adjusted pressure. This study aimed to investigate changes in the endotracheal tube cuff pressure using both manual and intermittent controls. MATERIALS AND METHODS A semi-experimental within-subject design was conducted. Fifty-nine intubated patients in the Mazandaran Intensive Care Units (ICUs) participated through convenience sampling in 2018. In the control condition, first, the cuff pressure was adjusted in 25 cm H2O then it was measured without manometer-pilot disconnection at 1 and 5 min intervals. In the intervention condition, cuff pressure was immediately adjusted in 25 cm H2O then it was measured with manometer-pilot disconnection in the 1st and 5th minutes. Data analysis was performed using Independent t-test, Chi-square test, and Phi coefficient. RESULTS The mean and Standard Deviation (SD) change of cuff pressure after 1 minute, from 25 cm H2O, in the intervention condition was 20.22 (3.53) cm H2O. The mean (SD) of this change in the control condition was 25.22 (3.39) cm H2O. This difference was significant (t 116 = 7.83, p < 0.001, d = 1.44). The mean (SD) change of cuff pressure after 5 minutes, from 25 cm H2O, in the intervention condition was 19.11 (2.98) cm H2O. The mean (SD) of this change in the control condition was 25.47 (4.53) cm H2O. This difference was significant (t 116 = 9.24, p < 0.001, d = 1.70). CONCLUSIONS The tracheal tube cuff pressure has been significantly reduced during manual intermittent measuring. Therefore, it is suggested that continuous cuff pressure monitoring and regulation should be used.
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Affiliation(s)
- Roghieh Nazari
- Amol Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Mojgan Panjoo
- Nursing Student, Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Salehpour-Omran
- Nursing Student, Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hamid Sharif Nia
- Amol Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ameneh Yaghoobzadeh
- Department of Geriatric Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
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Tapered-cuff versus cylindrical-cuff tracheal tube in preventing fluid leak: An in-vitro experimental study. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2018.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Aeppli N, Lindauer B, Steurer MP, Weiss M, Dullenkopf A. Endotracheal tube cuff pressure changes during manual cuff pressure control manoeuvres: An in-vitro assessment. Acta Anaesthesiol Scand 2019; 63:55-60. [PMID: 30132783 DOI: 10.1111/aas.13249] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 07/07/2018] [Accepted: 07/31/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Endotracheal tube (ETT) cuffs are designed to seal the lower airway for precise ventilation and to protect against ingress of pathogens from the pharyngeal space. Therefore, a minimal continuous cuff pressure must be maintained. Aim of this study was to analyse the course of cuff pressure in an in-vitro model during manual cuff pressure control manoeuvres. METHODS An artificial trachea was intubated with an appropriately sized ETT and cuff pressure set to 20 cm H2 O. Thirty-two experienced ICU nurses each performed six cuff pressure control manoeuvres (three times in two different ETTs) using a manual cuff pressure manometer. Course of cuff pressure from connecting the manometer to disconnecting it from the cuff pilot balloon was recorded using a pressure transducer. RESULTS There were 190 cuff pressure control manoeuvres suitable for analysis. In all control manoeuvres a cuff pressure below 20 cm H2 O was noted. In 20.0% of the control manoeuvres the cuff pressure dropped below 10 cm H2 O. Cuff pressure drops were mainly caused by initially connecting the manometer to the pilot balloon, less frequently by manipulating the pressure gauge of the manometer. Disconnecting the manometer after the control manoeuvre caused a cuff pressure drop in 78.1% of cases, contributing to a final cuff pressure below 20 cm H2 O in 31.3% of control manoeuvres. CONCLUSION Routine manual cuff pressure control manoeuvres in ETT cuffs result in considerable cuff pressure drops. This may have an impact on silent aspiration of pharyngeal contents passing along the cuff into the lower airway.
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Affiliation(s)
- Norbert Aeppli
- Department of Anaesthesiology and Intensive Care Medicine; Kantonsspital Frauenfeld; Frauenfeld Switzerland
| | - Bastian Lindauer
- Department of Anaesthesiology and Intensive Care Medicine; Kantonsspital Frauenfeld; Frauenfeld Switzerland
| | - Marc P. Steurer
- Department of Anesthesia and Perioperative Care; University of California; San Francisco California
| | - Markus Weiss
- Department of Anaesthesia and Children's Research Centre; University Children's Hospital; Zurich Switzerland
| | - Alexander Dullenkopf
- Department of Anaesthesiology and Intensive Care Medicine; Kantonsspital Frauenfeld; Frauenfeld Switzerland
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6
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Wen Z, Wei L, Chen J, Xie A, Li M, Bian L. Is continuous better than intermittent control of tracheal cuff pressure? A meta-analysis. Nurs Crit Care 2018; 24:76-82. [PMID: 30537009 DOI: 10.1111/nicc.12393] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/23/2018] [Accepted: 09/13/2018] [Indexed: 11/28/2022]
Abstract
AIM To compare and evaluate the efficacy and safety of continuous and intermittent control of cuff pressure. METHODS We performed a comprehensive and systematic meta-analysis of randomized controlled trials (RCTs) assessing the continuous and intermittent control of Pcuff by searching PUBMED, EMBASE and other such databases (from inception to 31 March 2018). Summary odds ratios or mean differences with 95% confidence intervals were calculated using a fixed- or random-effects model. MEASUREMENTS AND MAIN RESULTS Seven randomised controlled trials with 970 mechanically ventilated patients were included in this study. The continuous control of cuff pressure significantly reduced the incidence of cuff pressure < 20 cm H2 O (0.03 (OR) (95% CI: 0.01-0.07)), Pcuff > 30 cm H2 O (0.06 (95% CI: 0.03-0.15)) and VAP (0.39 (95% CI: 0.28-0.55)) when compared with intermittent control of cuff pressure. No significant differences in duration of MV (-1.94 (95% CI: -4.06 to -0.17)), length of ICU stay (-3.88 (95% CI: -9.00 to -1.23)) and mortality (0.99 (95% CI: 0.73-1.35)) were found between the two groups. CONCLUSIONS Continuous control of cuff pressure offers more benefits in stabilizing the cuff pressure and reducing the incidence of VAP, and more studies are warranted to further evaluate the role of continuous control of cuff pressure. RELEVANCE TO PRACTICE The continuous control of cuff pressure should be conducted whenever possible as it is the most ideal for the prognosis of MV patients.
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Affiliation(s)
- Zunjia Wen
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Li Wei
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Junyu Chen
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ailing Xie
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Mei Li
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lanzheng Bian
- Children's Hospital of Nanjing Medical University, Nanjing, China
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7
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Wang J, Su Z, Oto J, Kacmarek RM, Jiang Y, Liu S. Endotracheal catheter equipped with functional cuff produces clinically relevant positive end expiratory pressure: a bench study. J Clin Monit Comput 2018; 33:419-429. [PMID: 30073444 DOI: 10.1007/s10877-018-0189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 07/30/2018] [Indexed: 10/28/2022]
Abstract
Recently, we developed a novel endotracheal catheter with functional cuff (ECFC). Using such an ECFC and a regular ICU ventilator, we were able to generate clinically relevant tidal volume in a lung model and adult human sized animal. This ECFC allows co-axial ventilation without using a jet ventilator. The aim of this study was to determine if ECFC also could generate clinically relevant positive end expiratory pressure (PEEP). The experiment was conducted on a model lung and artificial trachea. Lung model respiratory mechanics were set to simulate those of an adult human being. The tip of the distal end of ECFC 14 or 19 Fr catheter was positioned in the artificial trachea 3 cm above the carina. The proximal end of ECFC was connected to an ordinary ICU ventilator. With 14 Fr catheter at respiratory rate 10 bpm, PEEP 0, 2.9, 8.2, 12.9 cmH2O was generated at preset PEEP 0, 5, 10, 15 cmH2O respectively and tidal volume was up to 393.4 ml. With 19 Fr catheter, PEEP was 0, 2.8, 7.6, 12.3 cmH2O, at preset PEEP 0, 5, 10, 15 cmH2O respectively and the tidal volume was up to 667.3 ml. With 14 Fr catheter at respiratory rate 20 bpm, PEEP was 0, 3.9, 9.6, 14.6 cmH2O at preset PEEP 0, 5, 10, 15 cmH2O respectively and tidal volume was up to 188.8 ml. With 19 Fr catheter, PEEP was 0, 3.6, 8.9, 13 cmH2O, at preset PEEP 0, 5, 10, 15 cmH2O respectively and tidal volume was up to 345.3 ml. ECFC enables clinicians to generate not only adequate tidal volume but also clinically relevant PEEP via co-axial ventilation using an ordinary ICU ventilator.
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Affiliation(s)
- Jingwen Wang
- Department of Reproductive Medicine, Gynecology and Obstetrics, The Affiliated Hospital of Jining Medical University, Jining, China.,Department of Anaesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Zhenbo Su
- Department of Anaesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA.,Department of Anaesthesia, China-Japan Union Hospital of Jilin University, Jilin, China
| | - Jun Oto
- Department of Anaesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA.,The Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Robert M Kacmarek
- Department of Anaesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA.,Respiratory Care Services, Massachusetts General Hospital, Boston, USA
| | - Yandong Jiang
- Department of Anaesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Shujie Liu
- Department of Anaesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA. .,Department of Anaesthesiology, The First Affiliated Hospital of Harbin Medical University, No. 23 Youzheng Street, Harbin, China.
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8
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Dat VQ, Geskus RB, Wolbers M, Loan HT, Yen LM, Binh NT, Chien LT, Mai NTH, Phu NH, Lan NPH, Hao NV, Long HB, Thuy TP, Kinh NV, Trung NV, Phu VD, Cap NT, Trinh DT, Campbell J, Kestelyn E, Wertheim HFL, Wyncoll D, Thwaites GE, van Doorn HR, Thwaites CL, Nadjm B. Continuous versus intermittent endotracheal cuff pressure control for the prevention of ventilator-associated respiratory infections in Vietnam: study protocol for a randomised controlled trial. Trials 2018; 19:217. [PMID: 29615093 PMCID: PMC5883270 DOI: 10.1186/s13063-018-2587-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 03/12/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Ventilator-associated respiratory infection (VARI) comprises ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). Although their diagnostic criteria vary, together these are the most common hospital-acquired infections in intensive care units (ICUs) worldwide, responsible for a large proportion of antibiotic use within ICUs. Evidence-based strategies for the prevention of VARI in resource-limited settings are lacking. Preventing the leakage of oropharyngeal secretions into the lung using continuous endotracheal cuff pressure control is a promising strategy. The aim of this study is to investigate the efficacy of automated, continuous endotracheal cuff pressure control in preventing the development of VARI and reducing antibiotic use in ICUs in Vietnam. METHODS/DESIGN This is an open-label randomised controlled multicentre trial. We will enrol 600 adult patients intubated for ≤ 24 h at the time of enrolment. Eligible patients will be stratified according to admission diagnosis (180 tetanus, 420 non-tetanus) and site and will be randomised in a 1:1 ratio to receive either (1) automated, continuous control of endotracheal cuff pressure or (2) intermittent measurement and control of endotracheal cuff pressure using a manual cuff pressure meter. The primary outcome is the occurrence of VARI, defined as either VAP or VAT during the ICU admission up to a maximum of 90 days after randomisation. Patients in both groups who are at risk for VARI will receive a standardised battery of investigations if their treating physician feels a new infection has occurred, the results of which will be used by an endpoint review committee, blinded to the allocated arm and independent of patient care, to determine the primary outcome. All enrolled patients will be followed for mortality and endotracheal tube cuff-related complications at 28 days and 90 days after randomisation. Other secondary outcomes include antibiotic use; days ventilated, in ICU and in hospital; inpatient mortality; costs of antibiotics in ICU; duration of ICU stay; and duration of hospital stay. DISCUSSION This study will provide high-quality evidence concerning the use of continuous endotracheal cuff pressure control as a method to reduce VARI, antibiotic use and hospitalisation costs and to shorten stay. TRIAL REGISTRATION ClinicalTrials.gov, NCT02966392 . Registered on November 9, 2016. Protocol version: 2.0; issue date March 3, 2017.
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Affiliation(s)
- Vu Quoc Dat
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.,Department of Infectious Diseases, Hanoi Medical University, Hanoi, Vietnam
| | - Ronald B Geskus
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Marcel Wolbers
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Huynh Thi Loan
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Lam Minh Yen
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Nguyen Thi Hoang Mai
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Nguyen Van Hao
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Hoang Bao Long
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Tran Phuong Thuy
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Vu Dinh Phu
- National Hospital for Tropical Diseases, Hanoi, Vietnam
| | | | | | - James Campbell
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Evelyne Kestelyn
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Heiman F L Wertheim
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Duncan Wyncoll
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Guy Edward Thwaites
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - H Rogier van Doorn
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - C Louise Thwaites
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Behzad Nadjm
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
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9
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Pérez-Granda MJ, Latorre MC, Alonso B, Hortal J, Samaniego R, Bouza E, Guembe M. Eradication of P. aeruginosa biofilm in endotracheal tubes based on lock therapy: results from an in vitro study. BMC Infect Dis 2017; 17:746. [PMID: 29202722 PMCID: PMC5715999 DOI: 10.1186/s12879-017-2856-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/26/2017] [Indexed: 02/08/2023] Open
Abstract
Background Despite the several strategies available for the management of biofilm-associated ventilator-associated pneumonia, data regarding the efficacy of applying antibiotics to the subglottic space (SS) are scarce. We created an in vitro model to assess the efficacy of antibiotic lock therapy (ALT) applied in the SS for eradication of Pseudomonas aeruginosa biofilm in endotracheal tubes (ETTs). Methods We applied 2 h of ALT to a P. aeruginosa biofilm in ETTs using a single dose (SD) and a 5-day therapy model (5D). We used sterile saline lock therapy (SLT) as the positive control. We compared colony count and the percentage of live cells between both models. Results The median (IQR) cfu counts/ml and percentage of live cells in the SD-ALT and SD-SLT groups were, respectively, 3.12 × 105 (9.7 × 104-0) vs. 8.16 × 107 (7.0 × 107-0) (p = 0.05) and 53.2% (50.9%-57.2%) vs. 91.5% (87.3%-93.9%) (p < 0.001). The median (IQR) cfu counts/ml and percentage of live cells in the 5D-ALT and 5D-SLT groups were, respectively, 0 (0-0) vs. 3.2 × 107 (2.32 × 107-0) (p = 0.03) and 40.6% (36.6%-60.0%) vs. 90.3% (84.8%-93.9%) (p < 0.001). Conclusion We demonstrated a statistically significant decrease in the viability of P. aeruginosa biofilm after application of 5D-ALT in the SS. Future clinical studies to assess ALT in patients under mechanical ventilation are needed.
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Affiliation(s)
- María Jesús Pérez-Granda
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | | | - Beatriz Alonso
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Hortal
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Rafael Samaniego
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Confocal Laser Scanning Microscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emilio Bouza
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Guembe
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain. .,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario "Gregorio Marañón", C/. Dr. Esquerdo, 46, 28007, Madrid, Spain.
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Mariyaselvam MZ, Marsh LL, Bamford S, Smith A, Wise MP, Williams DW. Endotracheal tubes and fluid aspiration: an in vitro evaluation of new cuff technologies. BMC Anesthesiol 2017; 17:36. [PMID: 28257624 PMCID: PMC5336650 DOI: 10.1186/s12871-017-0328-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/20/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aspiration of subglottic secretions past the endotracheal tube (ETT) cuff is a prerequisite for developing ventilator-associated pneumonia (VAP). Subglottic secretion drainage (SSD) ETTs reduce aspiration of subglottic secretions and have demonstrated lower VAP rates. We compared the performance of seven SSD ETTs against a non-SSD ETT in preventing aspiration below inflated cuffs. METHODS ETTs were positioned vertically in 2 cm diameter cylinders. Four ml of a standard microbial suspension was added above inflated cuffs. After 1 h, aspiration was measured and ETTs demonstrating no leakage were subjected to rotational movement and evaluation over 24 h. Collected aspirated fluid was used to inoculate agar media and incubated aerobically at 37 °C for 24 h. The aspiration rate, volume and number of microorganisms that leaked past the cuff was measured. Experiments were repeated (×10) for each type of ETT, with new ETTs used for each repeat. Best performing ETTs were then tested in five different cylinder diameters (1.6, 1.8, 2.0, 2.2 and 2.4 cm). Experiments were repeated as above using sterile water. Volume and time taken for aspiration past the cuff was measured. Experiments were repeated (×10) for each type of ETT. Results were analysed using non-parametric tests for repeated measures. RESULTS The PneuX ETT prevented aspiration past the cuff in all experiments. All other ETTs allowed aspiration, with considerable variability in performance. The PneuX ETT was statistically superior in reducing aspiration compared to the SealGuard (p < 0.009), KimVent (p < 0.002), TaperGuard (p < 0.004), Lanz (p < 0.001), ISIS (p < 0.001), SACETT (p < 0.001) and Soft Seal (p < 0.001) ETTs. Of the 4 ETTs tested in differing cylinder sizes, the PneuX significantly reduced aspiration across the range of diameters compared to the SealGuard (p < 0.0001), TaperGuard (p < 0.0001) and KimVent (p < 0.0001) ETTs. CONCLUSIONS ETTs showed substantial variation in fluid aspiration, relating to cuff material and design. Variability in performance was likely due to the random manner in which involutional folds form in the inflated ETT cuff. The PneuX ETT was the only ETT able to consistently prevent aspiration past the cuff in all experiments.
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Affiliation(s)
- Maryanne Z Mariyaselvam
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK.
| | - Lucy L Marsh
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK
| | - Sarah Bamford
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK
| | - Ann Smith
- School of Biosciences, Cardiff University, Cardiff, Wales, UK
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, Wales, UK
| | - David W Williams
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK
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Efficiency of an electronic device in controlling tracheal cuff pressure in critically ill patients: a randomized controlled crossover study. Ann Intensive Care 2016; 6:93. [PMID: 27704488 PMCID: PMC5050178 DOI: 10.1186/s13613-016-0200-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/29/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Despite intermittent control of tracheal cuff pressure (P cuff) using a manual manometer, cuff underinflation (<20 cmH2O) and overinflation (>30 cmH2O) frequently occur in intubated critically ill patients, resulting in increased risk of microaspiration and tracheal ischemic lesions. The primary objective of our study was to determine the efficiency of an electronic device in continuously controlling P cuff. The secondary objective was to determine the impact of this device on the occurrence of microaspiration of gastric or oropharyngeal secretions. METHODS Eighteen patients requiring mechanical ventilation were included in this prospective randomized controlled crossover study. They randomly received either continuous control of P cuff with Mallinckrodt® device for 24 h, followed by discontinuous control with a manual manometer for 24 h, or the reverse sequence. During the 48 h after randomization, P cuff was continuously recorded, and pepsin and alpha amylase were quantitatively measured in tracheal aspirates. P cuff target was 25 cmH2O. RESULTS Clinical characteristics were similar during the two study periods, as well as mean airway pressure. Percentage of time spent with cuff overinflation or underinflation was significantly lower during continuous control compared with routine care period [median (IQR) 0.8 (0.1, 2) vs 20.9 (3.1, 40.1), p = 0.0009]. No significant difference was found in pepsin [median (IQR) 230 (151, 300) vs 259 (134, 368), p = 0.95] or in alpha amylase level [median (IQR) 1475 (528, 10,333) vs 2400 (1342, 15,391), p = 0.19] between continuous control and routine care periods, respectively. CONCLUSIONS The electronic device is efficient in controlling P cuff, compared with routine care using a manometer. Further studies are needed to evaluate the impact of this device on intubation-related complications. Trial registration ClinicalTrials.gov Identifier: NCT01965821.
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