A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients

Effect of Perioperative Subglottic Secretion Drainage on Ventilator-Associated Pneumonia After Cardiac Surgery: A Retrospective, Before-and-After Study

OBJECTIVES

Although postoperative subglottic secretion drainage prevents ventilator-associated pneumonia (VAP) after cardiac surgery, its role during the perioperative period is unclear. For the present study, the effect of subglottic secretion drainage during and after cardiac surgery on postoperative VAP was investigated.

DESIGN

Retrospective, single-center, before-and-after study.

SETTING

Perioperative care of cardiac surgical patients in a tertiary university hospital.

PARTICIPANTS

Adult patients who underwent cardiac surgery from January 2013-December 2018.

INTERVENTIONS

Conventional and subglottic suctioning endotracheal tubes were used in the control and intervention groups before and after a change in institutional policy, respectively. In the intervention group, subglottic secretion drainage was performed continuously during surgery and intermittently after surgery.

MEASUREMENTS AND MAIN RESULTS

The risk of postoperative VAP, identified by the National Healthcare Safety Network surveillance definition algorithm, was compared by weighted logistic regression. Logistic regression analyses, with propensity score matching and inverse probability weighting, also were performed. A total of 2,576 patients were analyzed (control [n = 2108]; intervention [n = 468]). Postoperative VAP occurred less frequently in the intervention group (1/468 [0.2%]) compared with the control group (30/2,108 [1.4%]). In the multivariate weighted logistic regression analysis, the risk of VAP after cardiac surgery was significantly lower in the intervention group than in the control group (odds ratio 0.29; 95% confidence interval 0.14-0.58). Similar results were obtained in multivariate analyses after propensity score matching (odds ratio 0.04; 95% confidence interval 0.01-0.14) and inverse probability weighting (odds ratio 0.16; 95% confidence interval 0.05-0.42).

CONCLUSIONS

Routine perioperative subglottic secretion drainage using subglottic suctioning endotracheal tubes in patients undergoing cardiac surgery was associated with a reduction in the risk of VAP after surgery.

Sex/gender and additional equity characteristics of providers and patients in perioperative anesthesia trials: a cross-sectional analysis of the literature

Sex and gender, among other equity-related characteristics, influence the process of care and patients’ outcomes. Currently, the extent to which these characteristics are considered in the anesthesia literature remains unknown. This study assesses their incorporation in randomized controlled trials (RCTs) on anesthesia-related interventions, for both patients and healthcare providers. This is a cross-sectional analysis using an existing dataset derived from the anesthesia literature. The dataset originated from a scoping review searching MEDLINE, Embase, CINAHL, CENTRAL, and the Cochrane Database of Systematic reviews. RCTs investigating the effect of anesthesia-related interventions on mortality for adults undergoing surgery were included. Equity outcome measures were recorded for both patients and providers and assessed for inclusion in the study design, reporting of results, and analysis of intervention effects. Three-hundred sixty-one RCTs (n = 144,674) were included. Most RCTs (91%) reported patient sex/gender, with 58% of patients identified as male. There were 139 studies (39%), where 70% or more of the sample was male, compared to just 14 studies (4%), where 70% or more of the sample was female. Only 10 studies (3%) analyzed results by patient sex/gender, with one reporting a significant effect. There was substantial variation in how age was reported, although nearly all studies (98%) reported some measure of age. For healthcare providers, equity-related information was never available. Better consideration of sex/gender and additional health equity parameters for both patients and providers in RCTs is needed to improve evidence quality, and ultimately, patient care and outcome.

Subglottic secretion drainage for preventing ventilator-associated pneumonia: an overview of systematic reviews and an updated meta-analysis

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

Case-control study investigating parameters affecting ventilator-associated events in mechanically ventilated patients

We analyzed a set of clinical parameters using Cox proportional hazard regressions to yield significant factors associated with the development of ventilator-associated events. In our study, intubation site, certain comorbidities, morphine, prednisone, and nutrition emerged as factors. Additionally, we presented potential mechanisms that require further research to validate.

Subglottic secretion drainage for ventilator-associated pneumonia prevention: an underused efficient measure

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.

Influence of subglottic secretion drainage on the microorganisms of ventilator associated pneumonia: A meta-analysis for subglottic secretion drainage

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.

Efficacy of continuous versus intermittent subglottic secretion drainage in preventing ventilator-associated pneumonia in patients requiring mechanical ventilation: A single-center randomized controlled trial

Objective

Aspiration of subglottic secretion is a widely used intervention to prevent ventilator-associated pneumonia (VAP). This study aimed to compare the efficacy of continuous and intermittent subglottic secretion drainage (SSD) in preventing VAP.

Methods

A single-center randomized controlled trial was conducted on adult postoperative patients who were expected to undergo mechanical ventilation for more than 48 hours. Primary outcome measure was incidence of VAP and secondary outcome measures were length of mechanical ventilation and intensive-care unit (ICU) stay.

Results

Fifty-nine patients received continuous SSD, while 60 patients received intermittent SSD. Of these 119 patients, 88 (74%) were excluded and 15 and 16 patients were allocated to receive continuous and intermittent SSD, respectively. VAP was detected in 4 (26.7%) and 7 (43.8%) patients in the continuous and intermittent groups, respectively, (p=0.320). The length of mechanical ventilation was significantly shorter (p=0.034) in the continuous group (99.5±47.1 h) than in the intermittent group (159.9±94.5 h). The length of ICU stay was also shorter (p=0.0097) in the continuous group (6.3±2.1 days) than the intermittent group (9.8±4.8 days).

Conclusions

Although continuous SSD did not reduce the incidence of VAP, it reduced the length of mechanical ventilation and ICU stay when compared to intermittent SSD.

Would "Suction above Cuff" be a Better Option than the "Standard" Endotracheal Tube for the Prevention of Ventilator-Associated Pneumonia: A Randomized Study in Postoperative Neurological Patients

Context

Ventilator associated pneumonia is one the most common nosocomial infection encountered in the ICU patients. Despite of the implementation of the VAP prevention bundle, the incidence remains high. This can be attributed to the peritubal leak and the aspiration of the oropharyngeal secretions. The secretions further forms a nidus for the growth of organisms in the lower respiratory tract. In this study, a specialised tube, named 'suction above cuff endotracheal tube' is used, which has an additional suction port opening above the cuff. This is to facilitate timely aspiration of the secretion which pent-up above the cuff and gradually trickles down the trachea resulting in pneumonia.

Aim

to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurological post-operative patients and its impact on clinical outcome.

Settings and Design

60 patients of post-operative neurological cases aged ≥ 18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT.

Results

In this study involving neurological population, there was no significant difference in incidence of clinical and microbiological VAP between SETT and SACETT group, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation.

Effect of antibiotics administered via the respiratory tract in the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis

PURPOSE

We evaluated the effect of antibiotics administered via the respiratory tract to prevent the ventilator-associated pneumonia (VAP) in mechanically ventilated (MV) patients.

METHODS

We searched relevant articles for trials that evaluated the impact of prophylactic antibiotics administered through the respiratory tract on the occurrence of VAP. The end-point was the occurrence of VAP in MV patients.

RESULTS

We included 6 comparative trials involving 1158 patients (632 received prophylactic antibiotic). Our meta-analysis revealed that prophylactic antibiotics administered through the respiratory tract reduced the occurrence of VAP when compared to placebo or no treatment (OR 0.53; 95% CI 0.34-0.84). This effect was seen when the antibiotics were given by nebulization (OR 0.46; 95% CI 0.22-0.97), but not when they were administered by intratracheal instillation (OR 0.57; 95% CI 0.28-1.15). We did not find a significant difference between the compared groups in the intensive care unit (ICU) mortality (OR 0.89; 95% CI 0.64-1.25). Antibiotic prophylaxis did not impact occurrence of VAP due to multidrug resistant (MDR) pathogens (OR 0.67; 95% CI 0.17-2.62).

CONCLUSIONS

Prophylactic antibiotics administered through the respiratory tract by nebulization reduce the occurrence of VAP, without a significant effect on either the ICU mortality or occurrence of VAP due to MDR pathogens.

Endotracheal tubes and fluid aspiration: an in vitro evaluation of new cuff technologies

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.

Aspiration and the Risk of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is a major concern in the intensive care unit. It is estimated that the risk of developing VAP may be as high as 1% per ventilated day, and the attributable mortality approaches 50% in some series. A growing body of evidence implicates the role of microaspiration of contaminated oropharyngeal and perhaps gastroesophageal secretions into the airways as an integral step in the pathogenesis of VAP. In patients who have been intubated and mechanically ventilated for >72 hours, the majority of VAP is caused by enteric gram-negative organisms, presumably of gastrointestinal origin. As a result, strategies designed to minimize the risk of these contaminated secretions into the normally sterile airways are of paramount importance in terms of VAP prevention. This review highlights the important etiological role of the gut in the development of VAP and also discusses the evidence behind interventions that may modulate the risk of both aspiration and subsequent VAP.

Variable Definitions: Implications for the Prediction of Pulmonary Complications after Adult Cardiac Surgery

AIM

The aim of this paper was to review the implications that variable definitions have for the prediction of post-operative pulmonary complications after cardiac surgery.

METHOD

A review of the literature from 1980 to 2002. Selected studies demonstrated an original attempt to examine multivariate associations between pre, intra or post-operative antecedents and pulmonary outcomes in patients undergoing coronary artery bypass grafting (CABG). Reports that described the validation of established clinical prediction rules, testing interventions or research conducted in non-human cohorts were excluded from this review.

RESULTS

Consistently, variable factor and outcome definitions are combined for the development of multivariate prediction models that subsequently have limited clinical value. Despite being prevalent there are very few attempts to examine post-operative pulmonary complications (PPC) as endpoints in isolation. The trajectory of pulmonary dysfunction that precedes complications in the post-operative context is not clear. As such there is little knowledge of post-operative antecedents to PPC that are invariably excluded from model development.

CONCLUSION

Multivariate clinical prediction rules that incorporate antecedent patient and process factors from the continuum of cardiovascular care for specific pulmonary outcomes are recommended. Models such as these would be useful for practice, policy and quality improvement.

Influence of External Subglottic Air Flow on Dysphagic Tracheotomized Patients With Severe Brain Injury

OBJECTIVE

The aim of this study was to determine if external subglottic air flow (ESAF) influences swallowing frequency in severely dysphagic tracheotomized patients with brain injury.

METHODS

Ten patients were recruited at the neurological intensive care unit. The ESAF intervention was provided through the standard cuffed suction aid tracheotomy tube, which primarily is used to suction residual secretion volume from the subglottic area. Sessions were 150 minutes, and ESAF was provided at 60-65, 90-95, and 120-125 minutes at 3 L/min. Outcome measures included swallowing frequency (swallows/5 min) at 0-5 minutes (pre-baseline), 25-30 and 55-60 minutes (baseline/control), and 85-90, 115-120, and 145-150 minutes (postintervention). The residual secretion volume (ml) from the subglottic area was collected using a syringe at 0 minutes (pre-baseline), 30 and 60 minutes (baseline/ control), and at 90, 120, and 150 minutes (postintervention).

RESULTS

The mean (±SEM) swallowing frequency (swallows/5 min) increased from 0.60 ± 0.30 to 2.10 ± 0.70 during the ESAF intervention ( P < .001). The mean (±SEM) residual secretion volume reduced from 3.10 ± 0.31 ml to 0.50 ± 0.30 ml after the ESAF intervention ( P < .001).

CONCLUSION

The increase in swallowing frequency and reduction in residual secretion volume may indicate that ESAF influences swallowing parameters in patients with tracheotomy tubes.

Subglottic secretion suction for preventing ventilator-associated pneumonia: an updated meta-analysis and trial sequential analysis

Background

Potential benefits of subglottic secretion suction for preventing ventilator-associated pneumonia (VAP) are not fully understood.

Methods

We searched Cochrane Central, PubMed, and EMBASE up to March 2016 to identify randomized controlled trials (RCTs) that compared subglottic secretion suction versus non-subglottic secretion suction in adults with mechanical ventilation. Meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. The primary outcome was incidence of VAP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the level of evidence.

Results

Twenty RCTs (N = 3544) were identified. Subglottic secretion suction was associated with reduction of VAP incidence in four high quality trials (relative risk (RR) 0.54, 95 % confidence interval (CI) 0.40–0.74; p < 0.00001) and in all trials (RR = 0.55, 95 % CI 0.48– 0.63; p < 0.00001). Sensitivity analyses did not show differences in the pooled results. Additionally, the results of the above-mentioned analyses were confirmed in TSA. GRADE level was high. Subglottic secretion suction significantly reduced incidence of early onset VAP, gram-positive or gram-negative bacteria causing VAP, and duration of mechanical ventilation. It delayed the time-to-onset of VAP. However, no significant differences in late onset VAP, intensive care unit (ICU) mortality, hospital mortality, or ICU length of stay were found.

Conclusions

Subglottic secretion suction decreased VAP incidence and duration of mechanical ventilation and delayed VAP onset. However, subglottic secretion suction did not reduce mortality and length of ICU stay. Subglottic secretion suction is recommended for preventing VAP and for reducing ventilation length, especially in the population at high risk of early onset VAP.

Trial registration

A protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42015015715); registered on 5 January 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1527-7) contains supplementary material, which is available to authorized users.

Incidence and risk factors for aspiration pneumonia after cardiovascular surgery in elderly patients

OBJECTIVE

Pneumonia after cardiovascular surgery is the leading cause of mortality. Postoperative aspiration pneumonia becomes a critical issue in the management of cardiovascular surgery in the aging society. The aim of this study was to investigate the incidence and risk factors of aspiration pneumonia after cardiovascular surgery for elderly patients.

METHODS

This study consisted of 123 elderly patients (>65 years old) who survived their final extubation following cardiovascular surgery at Kinan Hospital. Patients were divided into aspiration pneumonia and no pneumonia groups. Postoperative aspiration pneumonia was diagnosed by two independent physicians according to the nursing- and healthcare-associated pneumonia guidelines by the Japanese Respiratory Society.

RESULTS

Among the patients, 12 (9.8 %) had aspiration pneumonia. There were no differences in patients' characteristics between the groups except for a history of cerebral vascular disorder (aspiration pneumonia 42 % vs no pneumonia 15 %, p = 0.04) and ejection fraction (EF) (aspiration pneumonia 56 ± 21 % vs no pneumonia 66 ± 13 %, p = 0.02). Only six (5 %) patients needed more than 12 h intubation. There was no difference in the operative factors between the groups. Neurological deficit was more frequently observed in the aspiration pneumonia group (33 vs 5 %, p = 0.005). Multivariable logistic regression analysis showed that the history of cerebral vascular disorder and neurological deficit after surgery was independent risk factors for aspiration pneumonia after cardiovascular surgery.

CONCLUSIONS

Our results could assist in screening elderly patients who should be more carefully evaluated before oral nutrition to minimize morbidity and mortality after cardiovascular surgery.

Efficacy of Hi-Lo Evac Endotracheal Tube in Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Poisoned Patients

Background. Ventilator-associated pneumonia (VAP) is the most common health care-associated infection. To prevent this complication, aspiration of subglottic secretions using Hi-Lo Evac endotracheal tube (Evac ETT) is a recommended intervention. However, there are some reports on Evac ETT dysfunction. We aimed to compare the incidence of VAP (per ventilated patients) in severely ill poisoned patients who were intubated using Evac ETT versus conventional endotracheal tubes (C-ETT) in our toxicology ICU. Materials and Methods. In this clinical randomized trial, 91 eligible patients with an expected duration of mechanical ventilation of more than 48 hours were recruited and randomly assigned into two groups: (1) subglottic secretion drainage (SSD) group who were intubated by Evac ETT (n = 43) and (2) control group who were intubated by C-ETT (n = 48). Results. Of the 91 eligible patients, 56 (61.5%) were male. VAP was detected in 24 of 43 (55.8%) patients in the case group and 23 of 48 (47.9%) patients in the control group (P = 0.45). The most frequently isolated microorganisms were S. aureus (54.10%) and Acinetobacter spp. (19.68%). The incidence of VAP and ICU length of stay were not significantly different between the two groups, but duration of intubation was statistically different and was longer in the SSD group. Mortality rate was less in SSD group but without a significant difference (P = 0.68). Conclusion. The SSD procedure was performed intermittently with one-hour intervals using 10 mL syringe. Subglottic secretion drainage does not significantly reduce the incidence of VAP in patients receiving MV. This strategy appears to be ineffective in preventing VAP among ICU patients.

Pulmonary Complications After Cardiac Surgery

Over the past two decades there has been a steady evolution in the practice of adult cardiac surgery with the introduction of “off-pump” surgery. However, respiratory complications remain a leading cause of postcardiac surgical morbidity and can prolong hospital stays and increase costs. The high incidence of pulmonary complications is in part due to the disruption of normal ventilatory function that is inherent to surgery in the thoracic region. Furthermore, patients undergoing such surgery often have underlying illnesses such as intrinsic lung disease (e.g., chronic obstructive pulmonary disease) and pulmonary dysfunction secondary to cardiac disease (e.g., congestive heart failure) that increase their susceptibility to postoperative respiratory problems. Given that many patients undergoing cardiac surgery are thus susceptiple to pulmonary complications, it is remarkable that more patients do not suffer from them during and after cardiac surgery. This is to a large degree because of advances in anesthetic, surgical and critical care that, for example, have reduced the physiological insults of surgery (e.g., better myocardial preservation techniques) and streamlined care in the immediate postoperative period (e.g., early extubation). Moreover, the development of minimally invasive surgery and nonbypass techniques are further evidence of the attempts at reducing the homeostatic disruptions of cardiac surgery. This review examines the available information on the incidences, consequences, and treatments of postcardiac surgery respiratory complications.

Use of endotracheal tubes with subglottic secretion drainage reduces ventilator-associated pneumonia in trauma patients

BACKGROUND

Patients sustaining traumatic injuries have a higher incidence of ventilator-associated pneumonia (VAP) compared with other critically ill patient populations. Previous studies of patients with predominantly medical diagnoses and use of endotracheal tubes allowing subglottic secretion drainage (ETT-SSD) have shown significant reduction in VAP rates. We hypothesized that the use of ETT-SSD would reduce VAP in trauma patients.

METHODS

A retrospective review from 2010 to 2014 of adult trauma patients orotracheally intubated for more than 48 hours was performed at a Level 1 trauma center. Patients were compared based on standard endotracheal tube (ETT) versus ETT-SSD for the primary outcome VAP per 1,000 ventilator days. The diagnosis of VAP was made by quantitative bronchoalveolar lavage cultures as defined by Centers for Disease Control and Prevention criteria. Patients with ETT-SSD were matched to patients with ETT based on age group, sex, mechanism of injury, head and chest Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS).

RESULTS

Of 1,135 patients included in the study, 667 patients had ETT and 468 had ETT-SSD. Groups did not differ by demographics, mechanism of injury, Glasgow Coma Scale (GCS) score, alcohol intoxication, or ISS. Patients with ETT-SSD had significantly higher head AIS score but lower chest AIS score. In matched cohorts, ETT-SSD had a lower VAP rate (5.7 vs. 9.3 for ETT, p = 0.03), decreased ventilator days (12 vs. 14, p = 0.04), and decreased intensive care unit length of stay (13 days vs. 16 days, p = 0.003).

CONCLUSION

After controlling for confounding factors, ETT-SSD decreased VAP rate, ventilator days, and intensive care unit length of stay in trauma patients. In this high-risk patient population, we recommend routine use of ETT-SSD to decrease VAP.

LEVEL OF EVIDENCE

Therapeutic/care management study, level III.

Comparison of suction above cuff and standard endotracheal tubes in neurological patients for the incidence of ventilator-associated pneumonia and in-hospital outcome: A randomized controlled pilot study

Background:

Ventilator-associated pneumonia (VAP) is a common complication with endotracheal intubation. The occurrence of VAP results in significant mortality and morbidity. Earlier studies have shown reduction in the incidence of VAP with subglottic secretion drainage. The incidence of VAP in neurologically injured patients is higher and can impact the neurological outcome. This study aimed to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurologically ill patients and its impact on clinical outcome.

Methods:

Fifty-four patients with neurological illnesses aged ≥18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT. All the VAP preventive measures were similar between two groups except for the difference in type of tube.

Results:

The data of 50 patients were analyzed. The incidence of clinical VAP was 20% in SETT group and 12% in SACETT group; (P = 0.70). The incidence of microbiological VAP was higher in the SETT group (52%) as compared to SACETT group (44%) but not statistically significant; (P = 0.78). There was no difference between the two groups for measured outcomes such as duration of intubation, mechanical ventilation, and Intensive Care Unit stay.

Conclusions:

In this pilot study in neurological population, a there was no significant difference in incidence of clinical and microbiological VAP was seen between SETT and SACETT, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation.

"Post intubation Laryngeal injuries in a pediatric intensive care unit of tertiary hospital in India: A Fibreoptic endoscopic study"

STUDY OBJECTIVES

To identify acute laryngeal injuries among pediatric patients intubated for more than 48hours, and to correlate these injuries with clinical variables.

SETTING

Pediatric Intensive Care Unit (PICU) of a tertiary level hospital in India.

PATIENTS AND METHODS

Prospective, observational study. Thirty-four children meeting the inclusion and exclusion criteria were recruited into the study after obtaining informed consent from the parents. A bedside, flexible, fiberoptic laryngoscopy was done within the first 24hours of extubation. Laryngeal injuries were documented and graded. Individual types of laryngeal injuries were correlated to the duration of intubation, size of the tube, the experience of the intubator and the patient's demographics. A repeat endoscopy was done in the outpatient department, 3-4 weeks after extubation, and findings noted.

RESULTS

97% had acute laryngeal injury, of which 88% were significant. Erythema was the most common form of injury. Duration of intubation, with a mean of 4.5 days, showed a trend towards significance (p=0.06) for association with subglottic narrowing. Laryngeal injuries were similar with both cuffed and uncuffed tubes. Age of the subject, size of the tube and skill level of the intubator did not correlate with the laryngeal injuries. 18% required intervention for post-extubation laryngeal lesions. Three (10%) children had post-extubation stridor, and of these, two needed surgical intervention (6%).

CONCLUSION

Post-extubation laryngeal injuries are not uncommon. Fiberoptic endoscopy is an inexpensive and cost-effective tool for bedside evaluation of post-intubation status in pediatric larynx. Early diagnosis of post-intubation laryngeal injuries in children can prevent long term sequelae. Hence, post-extubation fiberoptic laryngoscopy should be done routinely in pediatric population.

Efficacy of intermittent sub-glottic suctioning in prevention of ventilator-associated pneumonia- A preliminary study of 100 patients

Background and Aims:

Oropharyngeal colonisation followed by aspiration of contaminated secretions is the major cause for ventilator-associated pneumonia (VAP). Pooled secretions present in the sub-glottic area above inflated endotracheal tube cuff may be aspirated into the lower airways. It was hypothesised that intermittent suctioning of sub-glottic secretions would prevent VAP.

Methods:

Group I (n = 50) patients were intubated with HiLo Evac™ endotracheal (ET) tube with facility for sub-glottic suctioning, and Group II (n = 50) patients were intubated with HiLo Contour™ ET tube without such facility. In the Group I, sub-glottic suctioning was performed every 2 h. Incidence of VAP, mean ventilator days, Intensive Care Unit (ICU) stay and mortality were compared. Qualitative variables were reported as percentages and were compared by Chi-square test or unpaired two-tailed, Fisher's exact test, as appropriate, to analyse the significance of difference between the two groups.

Results:

The two groups were similar with respect to demographic characteristics. VAP was seen in 6% of patients in Group I and 22% of patients in Group II (P = 0.021). Both early- and late-onset VAPs were significantly reduced in Group I. Both ventilator days (8.0 vs. 6.45; P = 0.001) and ICU stay (8.33 vs. 6.33; P = 0.001) on the day of onset of VAP were significantly more in the Group I. Total ventilator days were significantly less (6.52 vs. 8.32; P = 0.006) with lower incidence of mortality (36% vs. 48%; P = 0.224) in the Group I.

Conclusion:

Intermittent sub-glottic suctioning reduces the incidence of VAP including late-onset VAP.

Tapered-cuff Endotracheal Tube Does Not Prevent Early Postoperative Pneumonia Compared with Spherical-cuff Endotracheal Tube after Major Vascular Surgery

Background

Patients undergoing major vascular surgery often develop postoperative pneumonia that impacts their outcomes. Conflicting data exist concerning the potential benefit of tapered-shaped cuffs on tracheal sealing. The primary objective of this study was to assess the efficiency of a polyvinyl chloride tapered-cuff endotracheal tube at reducing the postoperative pneumonia rate after major vascular surgery. Secondary objectives were to determine its impact on microaspiration, ventilator-associated pneumonia rate, and inner cuff pressure.

Methods

This prospective randomized controlled study included 109 patients who were randomly assigned to receive either spherical- (standard cuff) or taper-shaped (tapered cuff) endotracheal tubes inserted after anesthesia induction and then admitted to the intensive care unit after major vascular surgery. Cuff pressure was continuously recorded over 5 h. Pepsin and α-amylase concentrations in tracheal aspirates were quantified on postoperative days 1 and 2. The primary outcome was the early postoperative pneumonia frequency.

Results

Comparing the tapered-cuff with standard-cuff group, respectively, postoperative pneumonia rates were comparable (42 vs. 44%, P = 0.87) and the percentage (interquartile range) of cuff-pressure time with overinflation was significantly higher (16.1% [1.5 to 50] vs. 0.6% [0 to 8.3], P = 0.01), with a 2.5-fold higher coefficient of variation (20.2 [10.6 to 29.4] vs. 7.6 [6.2 to 10.2], P &lt; 0.001). Although microaspiration frequencies were high, they did not differ between groups.

Conclusion

For major vascular surgery patients, polyvinyl chloride tapered-cuff endotracheal tubes with intermittent cuff-pressure control did not lower the early postoperative pneumonia frequency and did not prevent microaspiration.

Use of the Blom Tracheotomy Tube with Suction Inner Cannula to Decontaminate Microorganisms from the Subglottic Space. A Proof of Concept

RATIONALE

Preventing pulmonary complications during mechanical ventilation via tracheotomy is a high priority.

OBJECTIVES

To investigate if the Blom tracheotomy tube with suction-above-the-cuff inner cannula reduced the quantity of normal flora and pathogens in supra- versus subglottic spaces.

METHODS

We enrolled 20 consecutive medical ICU adults requiring tracheostomy for mechanical ventilation in this proof-of-concept, prospective, single-center study. All participants received a Blom tracheotomy tube with suction-above-the-cuff inner cannula to decontaminate microorganisms from the supra- and subglottic spaces. Supra- and subglottic sputum samples were obtained for microbiologic analysis while an endotracheal tube was in place before tracheotomy and once per week for up to 4 weeks of mechanical ventilation after tracheotomy.

MEASUREMENTS AND MAIN RESULTS

Demographics, duration of endotracheal tube intubation, and duration of mechanical ventilation post-tracheotomy were recorded. There was a significant reduction for supraglottic (2.86 ± 1.11 [mean ± SD]) versus subglottic suction samples (2.48 ± 1.07) (paired t test, P = 0.048; Wilcoxon test, P = 0.045) when all data pairs for normal flora and pathogens were combined across times. There was a significant reduction of normal flora pooled across times in 19 data pairs for supraglottic (3.00 ± 1.05) versus subglottic suction samples (2.00 ± 0.94) (paired t test, P = 0.0004; Wilcoxon test, P = 0.0007). There was no significant reduction of pathogens pooled across times in 25 data pairs for supraglottic (2.76 ± 1.16) versus subglottic suction samples (2.84 ± 1.03) (paired t test, P = 0.75; Wilcoxon test, P = 0.83).

CONCLUSIONS

Proof-of-concept was confirmed. The Blom tracheotomy tube with disposable suction-above-the-cuff inner cannula decontaminated microorganisms from the subglottic space when normal flora and pathogens were combined. Future research should investigate if decreased quantity of normal flora and pathogens in the subglottic space reduces the incidence of ventilator-associated pulmonary complications in critically ill patients requiring ongoing mechanical ventilation via tracheotomy.

Impact of supra-cuff suction on ventilator-associated pneumonia prevention

Critically ill patients are intubated or tracheostomized because, in most cases, these individuals require invasive mechanical ventilation. The cannulae that are used include the cuff, which can act as a reservoir for oropharyngeal secretions, predisposing to ventilator-associated pneumonia. Studies have revealed that the suction of subglottic secretions through the dorsal suction lumen above the endotracheal tube cuff delays the onset and reduces the incidence of ventilator-associated pneumonia. The aim of this review is to assess published studies regarding the significance of using suction with a supra-cuff device for the prevention of ventilator-associated pneumonia in critically ill patients treated with orotracheal intubation or tracheostomy. Therefore, by searching national and international databases, a literature review was undertaken of studies published between the years 1986 and 2011. Few results were found relating the suction of subglottic secretions to decreased duration of mechanical ventilation and length of stay in the intensive care unit. The suction of subglottic secretions is ineffective in decreasing mortality but is effective in reducing the incidence of early-onset ventilator-associated pneumonia and hospital costs. Techniques involving continuous suction of subglottic secretions may be particularly efficient in removing secretions; however, intermittent suction appears to be the least harmful method. In conclusion, cannulae with a supra-cuff suction device enable the aspiration of subglottic secretions, providing benefits to critically ill patients by reducing the incidence of ventilator-associated pneumonia and, consequently, hospital costs - with no large-scale adverse effects.

Prehospital oral chlorhexidine does not reduce the rate of ventilator-associated pneumonia among critically ill trauma patients: A prospective concurrent-control study

PURPOSE

The purpose of the study was to test the hypothesis that prehospital oral chlorhexidine administered to intubated trauma patients will decrease the Clinical Pulmonary Infection Score (CPIS) during the first 2 days of hospitalization.

MATERIALS AND METHODS

Prospective interventional concurrent-control study of all intubated adult trauma patients transported by air ambulance to a 711-bed Midwestern academic trauma center over a 1-year period. Patients transported by 2 university-based helicopters were treated with oral chlorhexidine after intubation, and the control group was patients transported by other air transport services.

RESULTS

Sixty-seven patients were enrolled, of which 23 received chlorhexidine (9 patients allocated to the intervention were not treated). The change in CPIS score was no different between the intervention and control groups by intention to treat (1.06- vs 1.40-point reduction, P = .520), and no difference was observed in tracheal colonization (29.0% vs 36.7%, P = .586). No differences were observed in the rate of clinical pneumonia (8.7% vs 8.6%, P = .987) or mortality (P = .196) in the per-protocol chlorhexidine group.

CONCLUSIONS

The prehospital administration of oral chlorhexidine does not reduce the CPIS score over the first 48 hours of admission for intubated trauma patients. Further study should explore other prehospital strategies of reducing complications of critical illness.

Infection control in the intensive care unit

It is critical for health care personnel to recognize and appreciate the detrimental impact of intensive care unit (ICU)-acquired infections. The economic, clinical, and social expenses to patients and hospitals are overwhelming. To limit the incidence of ICU-acquired infections, aggressive infection control measures must be implemented and enforced. Researchers and national committees have developed and continue to develop evidence-based guidelines to control ICU infections. A multifaceted approach, including infection prevention committees, antimicrobial stewardship programs, daily reassessments-intervention bundles, identifying and minimizing risk factors, and continuing staff education programs, is essential. Infection control in the ICU is an evolving area of critical care research.

Impact of subglottic suctioning on the incidence of pneumonia after cardiac surgery: a retrospective observational study

OBJECTIVE

Continuous aspiration of subglottic secretions (CASS) has been found to decrease the incidence of pneumonia in the general intensive care unit (ICU) population, but its benefit in cardiac surgery patients is unclear. The present study aimed to determine whether the routine use of CASS in cardiac surgical patients was associated with decreased pneumonia.

DESIGN

A retrospective, single-center observational study.

SETTING

The study was conducted in a quaternary care cardiac surgery center and university research hospital.

PARTICIPANTS

4,880 patients undergoing cardiac surgery were studied.

INTERVENTIONS

The control group (no CASS) received a standard endotracheal tube and underwent surgery between April 1, 2007 and March 31, 2009. The intervention group (CASS) received a subglottic suctioning endotracheal tube and underwent surgery between June 1, 2009 and May 31, 2011. The primary outcome was the development of pneumonia, and the secondary outcomes were 30-day in-hospital mortality, ventilation time, need for tracheostomy, ICU length of stay (LOS), and hospital LOS.

MEASUREMENTS AND MAIN RESULTS

The unadjusted incidence of pneumonia was 1.9% in the CASS group and 5.6% in the control group (p<0.0001). The CASS group also had lower 30-day in-hospital mortality (2.1% v 3.3%; p = 0.007), median ventilation time (8.42 v 7.3 hours; p<0.0001), and shorter median ICU LOS (1.77 v 1.17 days; p<0.0004) compared with the control group. Tracheostomy rates and median hospital LOS did not differ between groups. After adjusting using multivariable modeling, CASS remained an independent risk predictor for pneumonia (odds ratio [OR] 0.342, 95% confidence interval [CI] 0.239-0.490) and ICU LOS (OR 0.817, 95% CI 0.718-0.931).

CONCLUSIONS

The universal implementation of CASS in a quaternary care cardiac surgical population was associated with a decreased incidence of pneumonia.

Association among duration of mechanical ventilation, cuff material of endotracheal tube, and postoperative nosocomial pneumonia in cardiac surgical patients: a prospective study

OBJECTIVES

Postoperative pulmonary complications are a burden for high-risk surgical patients with a risk of aspiration of subglottic secretions along the polyvinyl chloride cuff. The introduction of a polyurethane cuff diminishes secretion leakage with a decreased rate of pneumonia. The aim of the current analysis was to determine the time at which a polyurethane cuffed endotracheal tube might be advantageous to prevent aspiration in a setting of high-risk surgical patients.

METHODS

The present investigation is based on published data obtained in postoperative cardiac surgical patients undergoing operation from 2006 to 2007. Cuff pressure was kept between 20 and 26 cmH2O intraoperatively and in the intensive care unit. The current post hoc analysis determines (1) the discriminatory cutoff value of intubation duration for predicting postoperative pneumonia and (2) the potential factors associated with prolonged intubation.

RESULTS

Forty-three patients (32%) were diagnosed with early postoperative pneumonia. Receiver operating characteristics analysis revealed a cutoff value of 16.6 hours for the duration of mechanical ventilation to discriminate patients with postoperative pneumonia. A stepwise binary logistic regression analysis revealed that a polyvinyl chloride cuff was associated with a 10-fold increased risk for prolonged intubation.

CONCLUSIONS

The current analyses provide evidence that among cardiac surgical patients, mechanical ventilation more than 16.6 hours is associated with an increased likelihood of postoperative pneumonia.

Prevention of ventilator-associated pneumonia

Invasive mechanical ventilation (IMV) represents a risk factor for the development of ventilator-associated pneumonia (VAP), which develops at least 48h after admission in patients ventilated through tracheostomy or endotracheal intubation. VAP is the most frequent intensive-care-unit (ICU)-acquired infection among patients receiving IMV. It contributes to an increase in hospital mortality, duration of MV and ICU and length of hospital stay. Therefore, it worsens the condition of the critical patient and increases the total cost of hospitalization. The introduction of preventive measures has become imperative, to ensure control and to reduce the incidence of VAP. Preventive measures focus on modifiable risk factors, mediated by non-pharmacological and pharmacological evidence based strategies recommended by guidelines. These measures are intended to reduce the risk associated with endotracheal intubation and to prevent microaspiration of pathogens to the lower airways.

Infection control in the intensive care unit

Nosocomial infections are common in many hospital departments, but particularly so on the intensive care unit, where they affect some 20 to 30% of patients. While early diagnosis and appropriate treatment are, of course, important, perhaps the greatest challenge is in the application of techniques to limit the development of such infections. This review will briefly discuss some of the background pathophysiology and epidemiology of nosocomial infection, and then focus on general and infection-specific preventative strategies individually and as part of broader infection-control programs with infection surveillance.

Respiratory therapy device modifications to prevent ventilator-associated pneumonia

PURPOSE OF REVIEW

Ventilator-associated pneumonia (VAP) is a controversial entity in the field of critical care. After years of research and significant efforts from regulatory agencies and hospitals, this complication is still frequently affecting mechanically ventilated patients, making VAP an active battleground for research. As a result, several preventive measures have recently been tested in experimental and clinical trials. Our interest is focused on those innovations related to the endotracheal tube (ETT).

RECENT FINDINGS

Four ETT-related VAP causative mechanisms are reviewed, together with different associated potential solutions. Technologies such as the subglottic secretion drainage and the Mucus Slurper have been studied to eliminate subglottic secretion pooling. Novel designs for the cuff and the management of its pressure may avoid leakage. Antimicrobial coatings can prevent endoluminal biofilm formation, whereas using an ETT cleaning device may also be beneficial. Finally, preserving the tracheal ciliary function will keep our best physiologic protection active.

SUMMARY

VAP prevention strategies are a continuously evolving field. Being able to identify the most valuable ideas needs a deep understanding of the disease pathophysiology. The role of the ETT is crucial and there is need for our standards of care to improve. This may soon be possible with newer technologies becoming increasingly available to clinicians.

Management and prevention of ventilator-associated pneumonia caused by multidrug-resistant pathogens

Ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) pathogens is a leading healthcare-associated infection in mechanically ventilated patients. The incidence of VAP due to MDR pathogens has increased significantly in the last decade. Risk factors for VAP due to MDR organisms include advanced age, immunosuppression, broad-spectrum antibiotic exposure, increased severity of illness, previous hospitalization or residence in a chronic care facility and prolonged duration of invasive mechanical ventilation. Methicillin-resistant Staphylococcus aureus and several different species of Gram-negative bacteria can cause MDR VAP. Especially difficult Gram-negative bacteria include Pseudomonas aeruginosa, Acinetobacter baumannii, carbapenemase-producing Enterobacteraciae and extended-spectrum β-lactamase producing bacteria. Proper management includes selecting appropriate antibiotics, optimizing dosing and using timely de-escalation based on antiimicrobial sensitivity data. Evidence-based strategies to prevent VAP that incorporate multidisciplinary staff education and collaboration are essential to reduce the burden of this disease and associated healthcare costs.

Subglottic secretion drainage for preventing ventilator associated pneumonia: a meta-analysis

BACKGROUND

Ventilator associated pneumonia (VAP) in the intensive care unit (ICU) has been shown to be associated with significant morbidity and mortality.(1-3) It has been reported to affect between 9 and 27% of intubated patients receiving mechanical ventilation.(4-6) OBJECTIVE: A meta-analysis was undertaken to combine information from published studies of the effect of subglottic drainage of secretions on the incidence of ventilated associated pneumonia in adult ICU patients.

DATA SOURCES

Studies were identified by searching MEDLINE (1966 to January 2011), EMBASE (1980-2011), and CINAHL (1982 to January 2011).

REVIEW METHODS

Randomized trials of subglottic drainage of secretions compared to usual care in adult mechanically ventilated ICU patients were included in the meta-analysis.

RESULTS

Subglottic drainage of secretions was estimated to reduced the risk of VAP by 48% (fixed-effect relative risk (RR)=0.52, 95% confidence interval (CI), 0.42-0.65). When comparing subglottic drainage and control groups, the summary relative risk for ICU mortality was 1.05 (95% CI, 0.86-1.28) and for hospital mortality was 0.96 (95% CI, 0.81-1.12). Overall subglottic drainage effect on days of mechanical ventilation was -1.04 days (95% CI, -2.79-0.71).

CONCLUSION

This meta-analysis of published randomized control trials shows that almost one-half of cases of VAP may be prevented with the use of specialized endotracheal tubes designed to drain subglottic secretions. Time on mechanical ventilation may be reduced and time to development of VAP may be increased, but no reduction in ICU or hospital mortality has been observed in published trials.

Tracheotomy tubes with suction above the cuff reduce the rate of ventilator-associated pneumonia in intensive care unit patients

OBJECTIVES

We evaluated the effect of tracheotomy tubes that enable suction immediately above the cuff on the development of ventilator-associated pneumonia (VAP).

METHODS

Patients without preexisting pneumonia who required tracheotomy were randomly assigned to receive a tracheotomy tube with or without above-the-cuff suction. The suction tube provided 10 mm Hg of continuous wall suction while the tracheotomy tube cuff was inflated. Data regarding the development of VAP, time on the ventilator, and length of stay in the intensive care unit (ICU) were recorded and compared between groups.

RESULTS

Eighteen patients were randomized and prospectively evaluated. Nine patients received standard tracheotomy tubes, and 9 received suction-above-the-cuff tracheotomy tubes. The prevalences of VAP were 56% in the control group and 11% in the suction tracheotomy group (p = 0.02). The mean times on the ventilator were 18 +/- 14 days in the control group and 11 +/- 11 days in the suction group (p = 0.12). The mean lengths of ICU stay were 26 +/- 15 days in the control group and 18 +/- 15 days in the suction group (p = 0.14).

CONCLUSIONS

Use of suction-above-the-cuff tracheotomy tubes significantly decreases the incidence of VAP in ICU patients. There were trends toward decreased time on the ventilator and decreased length of stay in the ICU.

Role of topical antibiotic prophylaxis in prevention of bacterial translocation into upper trachea in nasally intubated patients undergoing tonsillectomies

INTRODUCTION

The human oropharynx and nasopharynx are home of different bacteria and fungi. The initial sterile endotracheal tube (ETT) transfers mechanically the bacteria from the nasopharynx and oropharynx to the sterile tracheobronchial tree. We investigated the efficacy of Neomycin-Bacitracin combination spray in the prevention of this bacterial translocation through its application over and inside the lumen of the endotracheal tubes preoperatively.

PATIENTS AND METHODS

Ninety patients aged (from 8 to 15 years) with ASA I and II were randomly assigned into 2 groups (45 patients for each): Group I; patients with naso-tracheal intubation which sprayed by placebo spray (Lidocaine) and group II; with naso-tracheal intubation that sprayed with antibiotic spray (combined Neomycin sulphate and Bacitracin) on the outside wall of the tube and inside its lumen. At the end of surgery and immediately after extubation, swabs were taken from the upper trachea using cotton tipped swab for bacterial growth. Inflammatory biomarkers were assessed preoperatively and postoperatively to detect any laboratory differences between both groups.

RESULTS

In the control group, all patients had heavy bacterial contamination and they were at either level 3 or 4 colony forming units. Thirty-two patients (71%) were at level 3 while 13 patients (29%) were at level 4. In the study group, there were 28 (62.2%) patients showed no bacterial growth, 15 (33.3%) patients were level 1, and 2 patients (4.4%) at level 2 colony forming units. There were no clinical differences between the 2 groups. Also, there was no significant difference between the 2 groups regarding to their postoperative body temperature although the inflammatory biomarkers were significantly higher in the control group.

CONCLUSION

Bacterial translocation by endotracheal intubation to the tracheobronchial tree could be prevented by local antibiotic spray application to outer and inner walls of the endotracheal tubes.

Reanimación y prevención de las infecciones nosocomiales

Los servicios de reanimación deben organizar de forma minuciosa la prevención de infecciones en sus enfermos, ya que éstos suelen estar inmunodeprimidos, están sometidos a múltiples procedimientos invasivos realizados por un personal sanitario variado, a menudo en situaciones de urgencia y a cualquier hora del día o de la noche. Las principales infecciones que hay que tratar de prevenir son las neumonías bacterianas adquiridas asociadas a ventilación mecánica (NAVM), las infecciones relacionadas con catéteres intravasculares y las infecciones urinarias asociadas al sondeo vesical. La incidencia de estas infecciones ha disminuido en la mayoría de los servicios que realizan un control cifrado, sobre todo gracias a la implantación de programas de mejora de la calidad. Las técnicas de prevención son múltiples y deben aplicarse simultáneamente. Incluyen medidas globales, como las modalidades de prevención de la transmisión cruzada (higiene de las manos, sobre todo) o de uso de antibióticos, concebidas para reducir la presión de selección de bacterias resistentes a éstos, así como medidas específicas relativas a la colocación y uso de cada uno de los dispositivos invasivos. Numerosas técnicas han demostrado su eficacia en estudios de buen nivel metodológico (higiene de las manos, apósitos para catéteres, etc.), mientras que otras siguen siendo objeto de controversias, por lo que las recomendaciones nacionales e internacionales se actualizan regularmente de acuerdo con los nuevos datos científicos. Estas medidas, implantadas de manera razonada en el marco de programas de mejora de la calidad, permiten obtener tasas muy bajas de infecciones relacionadas con el uso de catéteres vasculares y resultados menos satisfactorios con las NAVM, que justifican la necesidad de proseguir la investigación en este campo.

Rianimazione e prevenzione delle infezioni nosocomiali

I servizi di rianimazione devono organizzare la prevenzione delle infezioni nei loro pazienti in modo minuzioso, in quanto i pazienti sono spesso immunodepressi e subiscono gesti invasivi molteplici, realizzati da personale differente, spesso in situazioni di urgenza e a qualsiasi ora del giorno o della notte. Le principali infezioni che bisogna tentare di prevenire sono le polmoniti batteriche acquisite sotto ventilazione meccanica (PAVM), le infezioni su cateteri intravascolari e le infezioni urinarie su catetere vescicale. L’incidenza di queste infezioni è diminuita nella maggior parte dei servizi che ne effettuano un monitoraggio su base numerica, in particolare nel quadro di programmi di miglioramento della qualità. Le tecniche di prevenzione sono molteplici e devono essere applicate simultaneamente. Esse riguardano delle misure globali, come le modalità di prevenzione della trasmissione crociata (igiene delle mani, in particolare) o di utilizzo degli antibiotici nella prospettiva di ridurre la pressione di selezione di batteri resistenti agli antibiotici, così come delle misure specifiche relative al posizionamento e all’utilizzo di ciascuno dei dispositivi invasivi. Numerose tecniche si sono dimostrate efficaci in studi di buon livello metodologico (igiene delle mani, medicazioni dei cateteri, ecc.) mentre altre sono ancora oggetto di controversie, portando a raccomandazioni nazionali e internazionali regolarmente aggiornate in funzione dei nuovi dati scientifici. Queste misure, implementate in modo ragionato nel quadro di programmi di miglioramento della qualità, consentono di ottenere dei tassi molto bassi per quanto riguarda le infezioni dei cateteri vascolari e dei risultati meno buoni per le PAVM, illustrando la necessità di proseguire la ricerca in questo settore.

Technologic advances in endotracheal tubes for prevention of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is associated with high morbidity, mortality, and costs. Interventions to prevent VAP are a high priority in the care of critically ill patients requiring mechanical ventilation (MV). Multiple interventions are recommended by evidence-based practice guidelines to prevent VAP, but there is a growing interest in those related to the endotracheal tube (ETT) as the main target linked to VAP. Microaspiration and biofilm formation are the two most important mechanisms implicated in the colonization of the tracheal bronchial tree and the development of VAP. Microaspiration occurs when there is distal migration of microorganisms present in the secretions accumulated above the ETT cuff. Biofilm formation has been described as the development of a network of secretions and attached microorganisms that migrate along the ETT cuff polymer and inside the lumen, facilitating the transfer to the sterile bronchial tree. Therefore, our objective was to review the literature related to recent advances in ETT technologies regarding their impact on the control of microaspiration and biofilm formation in patients on MV, and the subsequent impact on VAP.

Subglottic secretion drainage for preventing ventilator-associated pneumonia: an updated meta-analysis of randomized controlled trials

BACKGROUND

Subglottic secretion drainage (SSD) has been shown to be associated with a lower incidence of ventilator-associated pneumonia (VAP) in a previous meta-analysis. However, a number of randomized controlled trials (RCTs) have been published since then, and so we aimed to conduct an updated meta-analysis.

METHODS

A systematic literature search of Pubmed, Embase, and Cochrane Central Register of Controlled Trials was conducted using specific search terms. Eligible studies were RCTs that compared SSD with standard endotracheal tube care in mechanically ventilated adult patients.

RESULTS

Ten RCTs with 2,213 patients were identified. SSD significantly reduced incidence of VAP (relative risk [RR] = 0.56, 95% confidence interval [CI]: 0.45-0.69, p < 0.00001) and early-onset VAP (RR = 0.23, 95% CI: 0.13-0.43, p < 0.00001), shortened ventilation duration by 1.55 days (95% CI: -2.40 to -0.71 days, p = 0.0003), and prolonged time to VAP by 3.90 days (95% CI: 2.56-5.24 days). Subgroup analyses suggested a significant reduction in incidence of VAP when stratified by intermittent (RR = 0.49, 95% CI: 0.34-0.71, p = 0.0001) and continuous SSD (RR = 0.61, 95% CI: 0.46-0.79, p = 0.0003). No significant differences were observed regarding incidence of late-onset VAP, overall mortality, or length of intensive care unit or hospital stay.

CONCLUSIONS

This updated meta-analysis confirmed that SSD was beneficial in preventing VAP. Furthermore, the effect of SSD on late-onset VAP, comparison between intermittent and continuous SSD, and safety of SSD in mechanically ventilated patients should be evaluated in future RCTs.

LEVEL OF EVIDENCE

I, meta-analysis.

Prevention of ventilator-associated pneumonia through aspiration of subglottic secretions: a systematic review and meta-analysis

Ventilator-associated pneumonia (VAP) is a subset of hospital-acquired pneumonias and is a serious, sometimes fatal, complication in patients who need mechanical ventilation. In addition, pay-for-performance initiative has placed increased emphasis on preventing nosocomial infections including VAP. Facilities may not be reimbursed for costs associated with prevalence infections. This article presents a review and meta-analysis of the prevention of VAP through the aspiration of subglottic secretion.