Effectiveness of continuous endotracheal cuff pressure control for the prevention of ventilator associated respiratory infections: an open-label randomised, controlled trial

Background

An endotracheal tube cuff pressure between 20 and 30 cmH₂O is recommended to prevent ventilator-associated respiratory infection (VARI). We aimed to evaluate whether continuous cuff pressure control (CPC) was associated with reduced VARI incidence compared with intermittent CPC.

Methods

We conducted a multicenter open-label randomized controlled trial in intensive care unit (ICU) patients within 24 hours of intubation in Vietnam. Patients were randomly assigned 1:1 to receive either continuous CPC using an automated electronic device or intermittent CPC using a manually hand-held manometer. The primary endpoint was the occurrence of VARI, evaluated by an independent reviewer blinded to the CPC allocation.

Results

We randomized 600 patients; 597 received the intervention or control and were included in the intention to treat analysis. Compared with intermittent CPC, continuous CPC did not reduce the proportion of patients with at least one episode of VARI (74/296 [25%] vs 69/301 [23%]; odds ratio [OR] 1.13; 95% confidence interval [CI] .77–1.67]. There were no significant differences between continuous and intermittent CPC concerning the proportion of microbiologically confirmed VARI (OR 1.40; 95% CI .94–2.10), the proportion of intubated days without antimicrobials (relative proportion [RP] 0.99; 95% CI .87–1.12), rate of ICU discharge (cause-specific hazard ratio [HR] 0.95; 95% CI .78–1.16), cost of ICU stay (difference in transformed mean [DTM] 0.02; 95% CI −.05 to .08], cost of ICU antimicrobials (DTM 0.02; 95% CI −.25 to .28), cost of hospital stay (DTM 0.02; 95% CI −.04 to .08), and ICU mortality risk (OR 0.96; 95% CI .67–1.38).

Conclusions

Maintaining CPC through an automated electronic device did not reduce VARI incidence.

Clinical Trial Registration

NCT02966392.

Continuous versus intermittent endotracheal cuff pressure control for the prevention of ventilator-associated respiratory infections in Vietnam: study protocol for a randomised controlled trial

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.

Effects of thermal stress and vitamin C on lipid peroxidation and fatty acid composition in the liver of thornfish Terapon jarbua

The effects of thermal stress and vitamin C were examined on the lipid peroxidation and fatty acid composition in the liver of thornfish. Small thornfish were cultured at 28, 32 and 36 degrees C and then fed diets with 0, 80, 400 and 2000 ppm vitamin C-supplement, respectively, for 8 weeks. Fish fed a diet without vitamin C supplement and cultured at 36 degrees C showed the highest values of hepatosomatic index and malondialdehyde, followed by fish fed a diet without vitamin C supplement and cultured at 32 degrees C. Lipid peroxidation in the liver of fish was elevated by high water temperature and prevented by vitamin C. The % of polyunsaturated fatty acid (PUFA) in the liver lipid was higher when fish were cultured at the lower water temperature. Vitamin C significantly reduced the % of PUFA and increased the % of saturated fatty acid (SFA) in the liver lipid. The % of SFA in the liver lipid was not affected by water temperature. We conclude that temperature and vitamin C significantly affected the lipid characters of liver in thornfish.

Thymoma and myasthenia gravis in a 4-year-old child. Case report and review of the literature

Thymomas are exceedingly rare in the first 20 years of life, and only a few well-documented cases are present in the literature. Thymomas in adults are commonly associated with other diseases, the most frequent being myasthenia gravis (MG). However, this association has been reported not to occur in childhood. The authors report the case of a 4-year and 10-month-old girl who presented with clinical evidence of MG before thoracotomy and who developed florid MG after thoracotomy for removal of an anterior mediastinal mass later documented to be a thymoma.