1
|
Chen Q, Yu X, Chen Y, He Q, Zhu B. Intermittent versus continuous control of tracheal cuff pressure in patients undergoing mechanical ventilation: A systematic review and meta-analysis. J Clin Nurs 2023. [PMID: 36724765 DOI: 10.1111/jocn.16619] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/13/2022] [Accepted: 11/28/2022] [Indexed: 02/03/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the effects and safety of intermittent versus continuous control of cuff pressure in patients with mechanical ventilation. BACKGROUND Tracheal cuff pressure management is vital to the prognosis of patients with mechanical ventilation. DESIGN A meta-analysis. METHODS This meta-analysis was conducted and reported according to the PRISMA checklist. We searched Pubmed, Embase, The Cochrane Library, BMJ Best Practice, Web of Science, ProQuest Dissertations, as well as the Chinese Biomedical Literature Database, Wanfang, and China national knowledge infrastructure databases up to 5 August 2022 for randomised controlled trials (RCTs) on the intermittent versus continuous control of cuff pressure. Review Manager 5.3 software was used for relevant data analysis. RESULTS A total of 18 RCTs involving 1998 patients with mechanical ventilation were included. The synthesised outcomes indicated that continuous control of cuff pressure is beneficial to reduce the incidence of ventilator-associated pneumonia (VAP) [RR = 0.41, 95%CI (0.35, 0.49)], aspiration [RR = 0.36, 95%CI (0.21, 0.63)], duration of mechanical ventilation [MD = -3.23, 95%CI (-4.66, -1.79)], length of ICU stay [MD = -4.12, 95%CI (-5.40, -2.83)], and increase the volume of subglottic drainage [MD = 18.54, 95%CI (16.50, 20.58)]. There was no significant difference in the mortality between two groups [RR = 1.01, 95%CI (0.84, 1.21)]. Egger regression analyses showed that there were no obvious publication biases in the synthesised results (all p > .05). CONCLUSIONS Existing evidence shows that compared with intermittent monitoring of cuff pressure, continuous monitoring of cuff pressure can reduce the occurrence of aspiration and VAP, shorten the patient's duration of mechanical ventilation and length of ICU stay. RELEVANCE TO CLINICAL PRACTICE Continuous monitoring of cuff pressure is more beneficial and should be promoted in clinical nursing care of patients undergoing mechanical ventilation.
Collapse
Affiliation(s)
- Qin Chen
- Department of Neurosurgery, Suzhou Kowloon Hospital, Shanghai Jiao Tong University, School of Medicine, Suzhou, China
| | - Xuemei Yu
- Department of Neurosurgery, Suzhou Kowloon Hospital, Shanghai Jiao Tong University, School of Medicine, Suzhou, China
| | - Yidan Chen
- Department of Neurosurgery, Suzhou Kowloon Hospital, Shanghai Jiao Tong University, School of Medicine, Suzhou, China
| | - Qin He
- Medical Center, Suzhou Kowloon Hospital, Shanghai Jiao Tong University, School of Medicine, Suzhou, China
| | - Biyun Zhu
- Department of Neurology, Suzhou Kowloon Hospital, Shanghai Jiao Tong University, School of Medicine, Suzhou, China
| |
Collapse
|
2
|
Seol G, Jin J, Oh J, Byun SH, Jeon Y. Pressure changes in tapered and cylindrical shaped cuff after extension of head and neck: A randomized controlled trial. World J Clin Cases 2022; 10:11419-11426. [PMID: 36387810 PMCID: PMC9649561 DOI: 10.12998/wjcc.v10.i31.11419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/31/2022] [Accepted: 09/29/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The proper cuff pressure of endotracheal tube (ET) plays an important role in sealing the airway and preventing airway complications during mechanical ventilation. The ET cuff shape affects the cuff pressure after positional change.
AIM To investigate cuff pressure between tapered and cylindrical cuff after extension of head and neck during nasal endotracheal intubation.
METHODS In a randomized clinical trial, 52 patients were randomized to one of two groups: cylindrical cuff or Tapered cuff. Cuff pressure with 22 cmH2O was applied to patients in the neutral position. After extension of head and neck, the cuff pressure was evaluated again and readjusted to 22 cmH2O. In addition, the extent of cephalad migration of ET tip was assessed and postoperative airway complications such as sore throat, and hoarseness were measured.
RESULTS The cuff pressure was higher in the tapered cuff (28.7 ± 1.0 cmH2O) than in the cylindrical cuff (25.5 ± 0.8 cmH2O) after head and neck extension (P < 0.001). The extent of cephalad migration of tube tip was greater in TaperGuard ET (18.4 ± 2.2 mm) than in conventional ET (15.1 ± 1.2 mm) (P < 0.001). The incidence of postoperative airway complications was comparable between two groups.
CONCLUSION After head and neck extension, the cuff pressure and the extent of cephalad migration of ET was greater in tapered cuff than in cylindrical cuff during nasal intubation, respectively.
Collapse
Affiliation(s)
- Gukjin Seol
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu 41944, South Korea
| | - Juhwa Jin
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Daegu 41944, South Korea
| | - Jinyoung Oh
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
| | - Sung-Hye Byun
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
| | - Younghoon Jeon
- Department of Anesthesiology and Pain Medicine, School of Dentistry, Kyungpook National University, Daegu 41944, South Korea
| |
Collapse
|
3
|
Saito M, Maruyama K, Mihara T, Hoshijima H, Hirabayashi G, Andoh T. Comparison of polyurethane tracheal tube cuffs and conventional polyvinyl chloride tube cuff for prevention of ventilator-associated pneumonia: A systematic review with meta-analysis. Medicine (Baltimore) 2021; 100:e24906. [PMID: 33655952 PMCID: PMC7939195 DOI: 10.1097/md.0000000000024906] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 01/30/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The aim of this meta-analysis with trial sequential analysis (TSA) was to evaluate the effect of a polyurethane (PU) tracheal tube cuff on the prevention of ventilator-associated pneumonia (VAP). METHODS We performed a systematic search using the MEDLINE database through PubMed, Cochrane Central Register of Controlled Trial, SCOPUS, and Web of Science.Randomized controlled trials comparing the incidence of VAP and clinically relevant outcomes between PU cuff tubes and polyvinyl chloride (PVC) cuff tubes in adult patients. Two authors independently extracted study details, patient characteristics, and clinical outcomes such as incidence of VAP, bacterial colonization of tracheal aspirate, duration of mechanical ventilation, ICU stay, and ICU mortality. RESULTS From 309 studies identified as potentially eligible, six studies with 1226 patients were included in this meta-analysis. All studies compared the incidence of VAP between PU cuffs and PVC cuffs. Use of a PU cuff was not associated with a reduction in VAP incidence (RR = 0.68; 95% CI, 0.45-1.03) with significant statistical heterogeneity (I2 = 65%). The quality of evidence was "very low." According to the TSA, the actual sample size was only 15.8% of the target sample size, and the cumulative Z score did not cross the trial sequential monitoring boundary for benefit. No positive impact was reported for the other relevant outcomes for PU cuffs. CONCLUSIONS The use of a PU cuff for mechanical ventilation did not prevent VAP. Further trials with a low risk of bias need to be performed.
Collapse
Affiliation(s)
- Minami Saito
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Takatsu-ku, Kawasaki
| | - Koichi Maruyama
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Takatsu-ku, Kawasaki
| | - Takahiro Mihara
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Kanazawa-ku, Yokohama, Kanagawa
| | - Hiroshi Hoshijima
- Department of Anesthesiology, Saitama Medical University, Moroyama Town, Iruma District, Saitama, Japan
| | - Go Hirabayashi
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Takatsu-ku, Kawasaki
| | - Tomio Andoh
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Takatsu-ku, Kawasaki
| |
Collapse
|
4
|
Nseir S, Koulenti D, Blot S. How to measure microaspiration of subglottic secretions in clinical research in intubated patients? Intensive Crit Care Nurs 2021; 63:103010. [PMID: 33461862 DOI: 10.1016/j.iccn.2020.103010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Saad Nseir
- Médecine Intensive Réanimation, CHU Lille, F-59000 Lille, France; Lille University, INSERM U995, Lille Inflammation Research International Center E2, Lille, France.
| | - Despoina Koulenti
- Second Critical Care Department, Attikon University Hospital, Athens, Greece; Burns, Trauma, and Critical Care Research Centre, UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Stijn Blot
- Burns, Trauma, and Critical Care Research Centre, UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Dept. of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| |
Collapse
|
5
|
Cotoia A, Spadaro S, Gambetti G, Koulenti D, Cinnella G. Pathogenesis-Targeted Preventive Strategies for Multidrug Resistant Ventilator-Associated Pneumonia: A Narrative Review. Microorganisms 2020; 8:microorganisms8060821. [PMID: 32486132 PMCID: PMC7356213 DOI: 10.3390/microorganisms8060821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/20/2020] [Accepted: 05/28/2020] [Indexed: 11/18/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU), accounting for relevant morbidity and mortality among critically ill patients, especially when caused by multidrug resistant (MDR) organisms. The rising problem of MDR etiologies, which has led to a reduction in treatment options, have increased clinician’s attention to the employment of effective prevention strategies. In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing MDR-VAP. Oral hygiene with Chlorhexidine (CHX), CHX body washing, selective oral decontamination (SOD) and/or digestive decontamination (SDD), multiple decontamination regimens, probiotics, subglottic secretions drainage (SSD), special cuff material and shape, silver-coated endotracheal tubes (ETTs), universal use of gloves and contact isolation, alcohol-based hand gel, vaporized hydrogen peroxide, and bundles of care have been addressed. The most convincing evidence came from interventions directly addressed against the key factors of MDR-VAP pathogenesis, especially when they are jointly implemented into bundles. Further research, however, is warranted to identify the most effective combination.
Collapse
Affiliation(s)
- Antonella Cotoia
- Department of Anesthesia and Intensive Care, University of Foggia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Viale Pinto 241, 71122 Foggia, Italy; (G.G.); (G.C.)
- Correspondence:
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Anesthesia and Intensive Care Section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant’Anna, Via Aldo Moro 8, 44124 Ferrara, Italy;
| | - Guido Gambetti
- Department of Anesthesia and Intensive Care, University of Foggia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Viale Pinto 241, 71122 Foggia, Italy; (G.G.); (G.C.)
| | - Despoina Koulenti
- 2nd Critical Care Department, Attikon University Hospital, 12462 Athens, Greece;
- UQCCR, Faculty of Medicine, The University of Queensland, Brisbane QLD 4029, Australia
| | - Gilda Cinnella
- Department of Anesthesia and Intensive Care, University of Foggia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Viale Pinto 241, 71122 Foggia, Italy; (G.G.); (G.C.)
| |
Collapse
|
6
|
Spapen H, Suys E, De Regt J, Troubleyn J, Jonckheer J, De Waele E. An endotracheal tube providing "pressurized sealing" prevents fluid leakage in mechanically ventilated critically ill patients: a pilot study. J Anesth 2019; 34:144-148. [PMID: 31691046 PMCID: PMC7224017 DOI: 10.1007/s00540-019-02707-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/22/2019] [Indexed: 01/27/2023]
Abstract
Microaspiration of bacteriologically contaminated oropharyngeal secretions alongside the cuff of an endotracheal tube (ETT) is a key mechanism for development of ventilator-associated pneumonia. We have constructed a prototype double-cuffed ETT equipped with a supplemental port in-between the cuffs through which continuous positive airway pressure (CPAP) is delivered. Pressure in the intercuff space propels secretions upwards and produces 100% tracheal sealing in an in vitro model. We conducted a 24 h study to investigate the sealing effect of this ETT in 12 critically ill mechanically ventilated patients. Methylene blue, instilled through a bronchoscope on top of the proximal cuff, was used as leakage tracer. Fiberoptic visualisation of the trachea was performed 1 h and 24 h thereafter. Leakage was confirmed if blue dye was detected on the tracheal mucosa beyond the tip of the ETT. In no patient, dye passed by the cuffs during the study period. Presence of the ETT did not interfere with ventilator settings, patient mobilization, physiotherapy, and technical acts. Overall, pressures in the intercuff space remained between 10 and 15 cmH2O. Excessive pressure swings were swiftly corrected by the CPAP system. A double-cuffed ETT, offering “pressurized sealing” of the trachea, safely and effectively prevented leakage during 24 h mechanical ventilation.
Collapse
Affiliation(s)
- Herbert Spapen
- Intensive Care Department, University Hospital Brussels, Vrije Universiteit Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Emiel Suys
- Intensive Care Department, University Hospital Brussels, Vrije Universiteit Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Jouke De Regt
- Intensive Care Department, University Hospital Brussels, Vrije Universiteit Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Joris Troubleyn
- Intensive Care Department, University Hospital Brussels, Vrije Universiteit Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Joop Jonckheer
- Intensive Care Department, University Hospital Brussels, Vrije Universiteit Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Elisabeth De Waele
- Intensive Care Department, University Hospital Brussels, Vrije Universiteit Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| |
Collapse
|
7
|
Kacmarek RM, Li Bassi G. Endotracheal tube management during mechanical ventilation: less is more! Intensive Care Med 2019; 45:1632-1634. [PMID: 31531713 DOI: 10.1007/s00134-019-05777-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Robert M Kacmarek
- Department of Anesthesiology, Harvard Medical School, Boston, MA, USA. .,Respiratory Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Gianluigi Li Bassi
- Division of Animal Experimentation, Critical Care Research Group, The Prince Charles Hospital, Chermside, Australia.,University of Queensland, Brisbane, Australia.,BITRECS Fellow, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| |
Collapse
|
8
|
Chair SY, Chan DWK, Cao X. The interaction of subglottic drainage, cuff pressure, and oral care on endotracheal tube fluid leakage: A benchtop study. Aust Crit Care 2019; 33:358-363. [PMID: 31248697 DOI: 10.1016/j.aucc.2019.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND The types of endotracheal tube, positive end-expiratory pressure (PEEP) level, endotracheal tube cuff pressure level, and nursing activity may influence the occurrence of pulmonary aspiration in ventilated patients with an endotracheal tube, but the evidence on their degree of influence is still inconclusive. AIM The aim of this study was to examine the effect of endotracheal tubes with or without subglottic secretion drainage on fluid leakage across endotracheal tube cuffs under different PEEP levels, different cuff pressures, and with or without oral care. METHOD This was a benchtop study with a multifactorial experimental design using two sets of airway. The two types of endotracheal tubes were tested through 12 scenarios with 240 combinations of different PEEP levels (0, 5, and 10 cmH2O), endotracheal tube cuff pressures (15 and 25 cmH2O), and oral care (with or without) using two sets of airway manikins. Each scenario lasted for 30 min, and fluid leakage was measured at the end of each scenario. Generalised Linear Model test was used to analyse fluid leak at 30 min (with and without interaction effect). RESULTS A total of 100 cases showed fluid leakage, with more fluid leakage occurring in low cuff pressure (15 cmH2O), no PEEP, and with oral care. Results of the Generalised Linear Model revealed that endotracheal tubes with subglottic secretion drainage, high PEEP (at 10 cmH2O), normal cuff pressure (at 25 cmH2O), and no oral care demonstrated a significant effect in reducing fluid leakage than endotracheal tubes without subglottic secretion drainage, low PEEP (at 5 or 0 cmH2O), and low cuff pressure (at 15 cmH2O) (all p < 0.001). However, only the interaction effect of endotracheal tubes with subglottic secretion drainage*high PEEP showed a significant effect on fluid leakage (p < 0.001), with the combination of endotracheal tube*no PEEP producing the greatest volume of fluid leak. CONCLUSION Using endotracheal tubes with subglottic secretion drainage, high PEEP, and normal cuff pressure and avoiding excessive endotracheal tube movement during oral care reduced fluid leakage. This study provided strong evidence to inform practice on reducing microaspiration in ventilated patients.
Collapse
Affiliation(s)
- Sek Ying Chair
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - David Wing Keung Chan
- School of Health Sciences, Caritas Institute of Higher Education, New Territories, Hong Kong, China
| | - Xi Cao
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
| |
Collapse
|
9
|
Rouzé A, Martin-Loeches I, Nseir S. Airway Devices in Ventilator-Associated Pneumonia Pathogenesis and Prevention. Clin Chest Med 2019; 39:775-783. [PMID: 30390748 DOI: 10.1016/j.ccm.2018.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Airway devices play a major role in the pathogenesis of microaspiration of contaminated oropharyngeal and gastric secretions, tracheobronchial colonization, and ventilator-associated pneumonia (VAP) occurrence. Subglottic secretion drainage is an effective measure for VAP prevention, and no routine change of ventilator circuit. Continuous control of cuff pressure, silver-coated tracheal tubes, low-volume low-pressure tracheal tubes, and the mucus shaver are promising devices that should be further evaluated by large randomized controlled trials. Polyurethane-cuffed, conical-shaped cuff, and closed tracheal suctioning system are not effective and should not be used for VAP prevention.
Collapse
Affiliation(s)
- Anahita Rouzé
- CHU Lille, Critical Care Center, bd du Pr Leclercq, Lille F-59000, France
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Trinity College, Welcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin 94568, Ireland
| | - Saad Nseir
- CHU Lille, Critical Care Center, bd du Pr Leclercq, Lille F-59000, France; Lille University, Medicine School, 1 Place de Verdun, Lille F-59000, France.
| |
Collapse
|
10
|
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]
|
11
|
Tapered Cuff versus Conventional Cuff for Ventilator-Associated Pneumonia in Ventilated Patients: A Meta-Analysis of Randomized Controlled Trials. Can Respir J 2019; 2019:7876417. [PMID: 30805066 PMCID: PMC6362499 DOI: 10.1155/2019/7876417] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/01/2019] [Indexed: 01/14/2023] Open
Abstract
Background Microaspiration of secretions around the tracheal cuff is a multifactorial process. Tracheal cuff shape might take a major part in its occurrence. The rationale for producing a taper-shaped cuff is established on the assumption that compared to a conventional cuff with a single fixed diameter, a continuum of minimum-to-maximum diameter sections might better fit the tracheal walls. Objectives The primary objective of this meta-analysis was to compare ventilator-associated pneumonia (VAP) between tapered-cuff intubation and conventional-cuff intubation. The secondary objective was to compare intensive care unit (ICU) mortality between tapered-cuff intubation and conventional-cuff intubation. Methods We searched the Cochrane Library, Embase, MEDLINE database through the PubMed search engine, and CINAHL from inception to April 2018. Randomized trials comparing VAP and ICU mortality between tapered-cuff intubation and conventional-cuff intubation in intubated adults were included. Two review authors assessed study quality and abstracted databasing on prespecified criteria independently. Results We pooled summary estimates from 5 trials evaluating tapered-cuff involving 774 participants. Compared to VAP, no statistically significant difference was observed between the tapered-cuff and conventional-cuff groups (OR 0.82, CI 0.61-1.12, z = 1.24, and p=0.21). No statistically significant difference was observed between the tapered-cuff and conventional-cuff groups with ICU mortality (OR 0.77, CI 0.55-1.08, z = 1.49, and p=0.14). Conclusions In this meta-analysis, the tapered-cuff tracheal tube may not be superior to the standard-cuff tracheal tube in reducing VAP and ICU mortality.
Collapse
|
12
|
Soussan R, Schimpf C, Pilmis B, Degroote T, Tran M, Bruel C, Philippart F. Ventilator-associated pneumonia: The central role of transcolonization. J Crit Care 2018; 50:155-161. [PMID: 30551046 DOI: 10.1016/j.jcrc.2018.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 12/03/2018] [Accepted: 12/04/2018] [Indexed: 01/15/2023]
Abstract
Ventilator-associated pneumonia remain frequent and serious diseases since they are associated with considerable crude mortality. Pathophysiology is centered on modifications of regional bacterial flora, especially tracheobronchial tree and oropharyngeal sphere. Bacterial migration from an anatomical area to another seems to be the main explanation of these alterations which are called "transcolonization". The association of transcolonization and lack of tightness of the endotracheal tube cuff provides a direct pathway for bacteria from the upper to the subglottic airways, eventually leading to ventilator-associated pneumonia. Although modification of bacterial flora has been largely studied, the mechanism which underlays the ability of the implantation, growing and interactions with the local microbiome that leads to the observed transcolonization remains to be more clearly deciphered. The aim of our review is to emphasize the cornerstone importance of the "transcolonization" as a nosological entity playing a central role in ventilator-associated pneumonia.
Collapse
Affiliation(s)
- Romy Soussan
- Medical and Surgical Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Caroline Schimpf
- Medical and Surgical Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Benoît Pilmis
- Antimicrobial Stewardship Team, Microbiology Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Thècle Degroote
- Medical and Surgical Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Marc Tran
- Medical and Surgical Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Cédric Bruel
- Medical and Surgical Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - François Philippart
- Medical and Surgical Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France; Endotoxins, Structures and Host Response, Department of Microbiology, Institute for Integrative Biology of the Cell, UMR 9891 CNRS-CEA-Paris Saclay University, 98190 Gif-sur-Yvette, France.
| | | |
Collapse
|
13
|
Sohn HM, Baik JS, Hwang JY, Kim SY, Han SH, Kim JH. Devising negative pressure within intercuff space reduces microaspiration. BMC Anesthesiol 2018; 18:181. [PMID: 30509183 PMCID: PMC6278018 DOI: 10.1186/s12871-018-0643-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 11/20/2018] [Indexed: 02/07/2023] Open
Abstract
Background Microaspiration past the tracheal tube cuffs causes ventilator-associated pneumonia. The objective of the current study was to evaluate whether creating negative pressure between the tracheal double cuffs could block the fluid passage past the tracheal tube cuffs. Methods A new negative pressure system was devised between the double cuffs through a suction hole in the intercuff space. Blue-dyed water was instilled above the cuff at negative suction pressures of − 54, − 68, − 82, − 95, − 109, − 122, and − 136 cmH2O, and the volume leaked was measured in an underlying water trap after 10 min. Leakage tests were also performed during positive pressure ventilation, and using higher-viscosity materials. The actual negative pressures delivered at the hole of double cuffs were obtained by placing microcatheter tip between the intercuff space and the artificial trachea. Results No leakage occurred past the double cuff at − 136 cmH2O suction pressure at all tracheal tube cuff pressures. The volume leaked decreased significantly as suction pressure increased. When connected to a mechanical ventilator, no leakage was found at − 54 cmH2suction pressure. Volume of the higher-viscosity materials (dynamic viscosity of 63–108 cP <cP> and 370–430 cP) leaked was small compared to that of normal saline (0.9–1.1 cP). The pressures measured in the intercuff space corresponded to 3.8–5.9% of those applied. Conclusions A new prototype double cuff with negative pressure in the intercuff space completely prevented water leakage. The negative pressure transmitted to the tracheal inner wall was a small percentage of that applied.
Collapse
Affiliation(s)
- H M Sohn
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - J S Baik
- Department of Anesthesiology and Pain Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - J Y Hwang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - S Y Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - S H Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University Medical College, Seoul, Republic of Korea
| | - J H Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea. .,Department of Anesthesiology and Pain Medicine, Seoul National University Medical College, Seoul, Republic of Korea.
| |
Collapse
|
14
|
Biderman P, van Heerden PV, Avitzur Y, Iakobishvili Z, Singer P. The efficacy of a novel peristaltic feeding tube (PFT) in reducing reflux and aspiration of gastric contents in mechanically ventilated patients. CLINICAL NUTRITION EXPERIMENTAL 2018. [DOI: 10.1016/j.yclnex.2018.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
15
|
Orotracheal tube as a risk factor for lower respiratory tract infection: preliminary data from a randomised trial. Wien Klin Wochenschr 2018; 130:328-334. [PMID: 29340765 DOI: 10.1007/s00508-017-1304-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 12/13/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE The aim of the study was to investigate whether polyurethane (PU) endotracheal tubes, continuous measurements of cuff pressure and aspiration of the subglottic space as a bundle of parameters could reduce patients' risk for developing ventilator associated pneumonia (VAP). METHODS Two groups of patients that differed only in terms of endotracheal tubes and intubation intervention were compared. Group A was ventilated using PU tubes a with conical cuff; they also had continuous cuff pressure measurement and continuous subglottic aspiration. Group B was ventilated using PVC tubes with a cylindrical cuff; the patients underwent intermittent cuff pressure measurement and intermittent subglottic aspiration. RESULTS Seven patients in group A (13.2%) and 18 in group B (36.0%) out of 103 were diagnosed with VAP. VAP patients were in general older, stayed longer in the ICU and were ventilated significantly longer compared with the patients with no VAP. Eight more patients in group B died compared with group A. Moreover, subjects in group A survived longer. Patient age, hours on mechanical ventilation, and days on an ICU were all positively associated with the occurrence of VAP. CONCLUSIONS Prevention parameters in ventilation (PU cuff, conical cuff, continuous subglottic drainage and continuous cuff pressure measurement) could prevent the incidence of VAP in ICU patients.
Collapse
|
16
|
Significance of Mini Bronchoalveolar Lavage Fluid Amylase Level in Ventilator-Associated Pneumonia: A Prospective Observational Study. Crit Care Med 2017; 46:71-78. [PMID: 29053492 DOI: 10.1097/ccm.0000000000002774] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Aspiration of oropharyngeal or gastric contents in intubated patients can lead to ventilator-associated pneumonia. Amylase in respiratory secretion has been reported as a possible marker of aspiration. We studied whether elevated α-amylase in mini bronchoalveolar lavage specimens can be suggestive of ventilator-associated pneumonia in intubated patients with high clinical suspicion. DESIGN Prospective single-center observational study. SETTING Department of Critical Care Medicine, tertiary care academic institute. PATIENTS Adult patients on mechanical ventilation for more than 48 hours with with clinically suspected ventilator-associated pneumonia as per defined criteria, admitted between December 2014 and May 2016. METHODS Mini bronchoalveolar lavage samples were collected within 72 hours of endotracheal intubation. Samples were sent for α-amylase level assay and quantitative culture. Ventilator-associated pneumonia was confirmed from mini bronchoalveolar lavage microbial culture of greater than or equal to 10 cfu/mL, and patients were divided into ventilator-associated pneumonia and no ventilator-associated pneumonia groups. Pre- and postintubation risk factors for aspiration were also noted. RESULTS The prevalence of ventilator-associated pneumonia was 64.9% among 151 patients in whom it was clinically suspected. Median (interquartile range) mini bronchoalveolar lavage α-amylase levels in ventilator-associated pneumonia and no ventilator-associated pneumonia groups on the day of study inclusion were 287 U/L (164-860 U/L) and 94 U/L (59-236 U/L), respectively (p < 0.001). Median (interquartile range) α-amylase levels in patients with 0, 1, 2, and 3 preintubation risk factors were 65 U/L (35-106 U/L), 200 U/L (113-349 U/L), 867 U/L (353-1,425 U/L), and 3,453 U/L (1,865-4,304 U/L), respectively (p < 0.001) and 472 U/L (164-1,452 U/L) and 731 U/L (203-1,403 U/L) in patients with 1 and 2 postintubation risk factors, respectively (p < 0.001). A mini bronchoalveolar lavage α-amylase of 163 U/L or more yielded sensitivity and specificity of 73% and 68.6%, respectively, with area under the receiver operating characteristic curve of 0.746 (95% CI, 0.66-0.83). CONCLUSIONS Patients with ventilator-associated pneumonia within 72 hours from intubation have significantly elevated α-amylase concentrations in mini bronchoalveolar lavage fluid. Mini bronchoalveolar lavage α-amylase concentrations increase with increasing number of aspiration risk factors.
Collapse
|
17
|
Modification of Tracheal Cuff Shape and Continuous Cuff Pressure Control to Prevent Microaspiration in an Ex Vivo Pig Tracheal Two-Lung Model. Crit Care Med 2017; 45:e1262-e1269. [PMID: 29019852 DOI: 10.1097/ccm.0000000000002764] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Microaspiration of subglottic secretions plays a pivotal role in ventilator-associated pneumonia. Impact of endotracheal tube cuff material and shape on tracheal sealing performance remains debated. The primary objective was to compare the tracheal sealing performance of polyvinyl chloride tapered, cylindrical and spherical cuffs. Secondary objectives were to determine the impact of continuous cuff pressure control on sealing performance and pressure variability. DESIGN Prospective randomized ex vivo animal study. SETTING French research laboratory. SUBJECTS Seventy-two ex vivo pig tracheal two-lung blocks. INTERVENTIONS Blocks were randomly intubated with cylindrical (n = 26), tapered (n = 24), or spherical (n = 22) polyvinyl chloride endotracheal tube cuffs. Two milliliter of methylene blue were instilled above the cuff to quantify microaspirations, and lungs were ventilated for 2 hours. Continuous cuff pressure control was implemented in 33 blocks. MEASUREMENTS AND MAIN RESULTS Cuff pressures were continuously recorded, and after 2 hours, a microaspiration score was calculated. Tapered cuffs improved cuff sealing performance compared with spherical cuffs with or without continuous cuff pressure control. Compared with spherical cuffs, tapered cuffs reduced the microaspiration score without and with continuous pressure control by 65% and 72%, respectively. Continuous cuff pressure control did not impact sealing performance. Tapered cuffs generated higher cuff pressures and increased the time spent with overinflation compared with spherical cuffs (median [interquartile range], 77.9% [0-99.8] vs. 0% [0-0.5]; p = 0.03). Continuous cuff pressure control reduced the variability of tapered and spherical cuffs likewise the time spent with overinflation of tapered and cylindrical cuffs. CONCLUSIONS Polyvinyl chloride tapered cuffs sealing enhanced performance at the cost of an increase in cuff pressure and in time spent with overinflation. Continuous cuff pressure control reduced the variability and normalized cuff pressures without impacting sealing performance.
Collapse
|
18
|
[Ventilator-associated pneumonia (VAP) : A risk already at the time of anesthetic induction]. Anaesthesist 2017; 66:122-127. [PMID: 27942786 DOI: 10.1007/s00101-016-0250-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is one of the most common and preventable infections in mechanically ventilated patients. It is associated with a high mortality rate. To prevent VAP, various strategies address this issue using "VAP-bundles", which are implemented in many intensive care units. The risk of acquiring VAP starts with the induction of anesthesia, strictly speaking at the time of intubation. This article considers measures to prevent VAP during general anesthesia in adult patients (>18 years). Procedures beyond standard hygienic precautions for VAP prevention are reviewed. METHODS A literature search in different databases (PubMed, Cochrane, Ovid und CINAHL) over the last five years. RESULTS Beyond standard hygienic precautions, microaspiration should be avoided to prevent VAP. During mechanical ventilation at least 5 cm H2O PEEP is advised. Continuous monitoring and adjustment of cuff pressure is necessary. All patients mechanically ventilated after general anesthesia for more than 24 h should be intubated with an ETT with a port for subglottic suctioning.
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Randomized Pilot Trial of Two Modified Endotracheal Tubes To Prevent Ventilator-associated Pneumonia. Ann Am Thorac Soc 2016; 13:72-80. [PMID: 26523433 DOI: 10.1513/annalsats.201506-346oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Ventilator-associated pneumonia (VAP) is a prevalent and costly nosocomial infection related to instrumentation of the airway with an endotracheal tube (ETT), enabling microaspiration of contaminated secretions. Modification of the ETT design to reduce microaspiration and/or biofilm formation may play an important role in VAP prevention. However, there is insufficient evidence to provide strong recommendations regarding the use of modified ETT and unaddressed safety concerns. OBJECTIVES We performed a pilot randomized controlled trial comparing two modified ETTs designed specifically to prevent VAP, with the standard ETT, to test the feasibility of and inform planning for a large, pivotal, randomized trial. METHODS This study was conducted with institutional review board approval under exception from informed consent. We randomized in a blinded fashion patients undergoing emergency endotracheal intubation both out of and in hospital to receive one of three different ETT types: (1) a polyurethane-cuffed tube (PUC-ETT), (2) a polyurethane-cuffed tube equipped with a port for continuous aspiration of subglottic secretions (PUC-CASS-ETT), or a (3) standard polyvinylchloride-cuffed tube (PVC-ETT). In addition to investigating feasibility and safety, the study coprimary end points were tracheal bacterial colonization reaching a cfu count >10(6) cfu per milliliter and the incidence of invasively diagnosed VAP. MEASUREMENTS AND MAIN RESULTS A total of 102 subjects were randomized and met the eligibility criteria. Randomization procedures performed well and integrity of blinding at randomization was maintained. The majority of intubations occurred in the hospital setting (n = 77), and the remainder occurred out of hospital (n = 25). Compared with the PVC-ETT, there were no significant differences in tracheal colonization for PUC-ETT (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.31-3.09) or for PUC-CASS-ETT (OR, 1.26; 95% CI, 0.42-3.76). There were no differences in the risk of invasively diagnosed VAP (OR, 1.14; 95% CI, 0.21-6.08 for PUC-ETT; OR, 1.47; 95% CI, 0.30-7.10 for PUC-CASS-ETT), or of clinically diagnosed VAP by either clinical signs or chest radiograph criteria. We did not observe unexpected or serious adverse events related to the devices. CONCLUSIONS A randomized trial of ETTs inserted during emergency intubation for the prevention of VAP is feasible and did not appear to carry heightened safety concerns. These preliminary data did not suggest different patterns of tracheal colonization or occurrence of VAP among the study groups. Clinical trial registered with www.clinicaltrials.gov (NCT01744483).
Collapse
|
21
|
Blot SI, Rello J, Koulenti D. The value of polyurethane-cuffed endotracheal tubes to reduce microaspiration and intubation-related pneumonia: a systematic review of laboratory and clinical studies. Crit Care 2016; 20:203. [PMID: 27342802 PMCID: PMC4921025 DOI: 10.1186/s13054-016-1380-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 06/07/2016] [Indexed: 11/10/2022] Open
Abstract
Background When conventional high-volume, low-pressure cuffs of endotracheal tubes (ETTs) are inflated, channel formation due to folds in the cuff wall can occur. These channels facilitate microaspiration of subglottic secretions, which is the main pathogenic mechanism leading to intubation-related pneumonia. Ultrathin polyurethane (PU)-cuffed ETTs are developed to minimize channel formation in the cuff wall and therefore the risk of microaspiration and respiratory infections. Methods We systematically reviewed the available literature for laboratory and clinical studies comparing fluid leakage or microaspiration and/or rates of respiratory infections between ETTs with polyvinyl chloride (PVC) cuffs and ETTs with PU cuffs. Results The literature search revealed nine in vitro experiments, one in vivo (animal) experiment, and five clinical studies. Among the 9 in vitro studies, 10 types of PU-cuffed ETTs were compared with 17 types of PVC-cuffed tubes, accounting for 67 vs. 108 experiments with 36 PU-cuffed tubes and 42 PVC-cuffed tubes, respectively. Among the clinical studies, three randomized controlled trials (RCTs) were identified that involved 708 patients. In this review, we provide evidence that PU cuffs protect more efficiently than PVC cuffs against fluid leakage or microaspiration. All studies with leakage and/or microaspiration as the primary outcome demonstrated significantly less leakage (eight in vitro and two clinical studies) or at least a tendency toward more efficient sealing (one in vivo animal experiment). In particular, high-risk patients intubated for shorter periods may benefit from the more effective sealing capacity afforded by PU cuffs. For example, cardiac surgery patients experienced a lower risk of early postoperative pneumonia in one RCT. The evidence that PU-cuffed tubes prevent ventilator-associated pneumonia (VAP) is less robust, probably because microaspiration is postponed rather than eliminated. One RCT demonstrated no difference in VAP risk between patients intubated with either PU-cuffed or PVC-cuffed tubes, and one before-after trial demonstrated a favorable reduction in VAP rates following the introduction of PU-cuffed tubes. Conclusions Current evidence can support the use of PU-cuffed ETTs in high-risk surgical patients, while there is only very limited evidence that PU cuffs prevent pneumonia in patients ventilated for prolonged periods. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1380-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Stijn I Blot
- Department of Internal Medicine, Ghent University, Campus UZ Gent, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Jordi Rello
- CIBERES, Universitat Autonòma de Barcelona, Barcelona, Spain
| | - Despoina Koulenti
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.,2nd Critical Care Department, Attikon University Hospital, Athens, Greece
| |
Collapse
|
22
|
Avitzur Y, van Heerden PV, Dayan L, Pintel O, Skopek J, Siman-Tov Y, McClave S, Bassi GL, Torres A, Singer P. Development of a device to reduce gastro-esophageal reflux in critically ill patients. CLINICAL NUTRITION EXPERIMENTAL 2016. [DOI: 10.1016/j.yclnex.2016.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
23
|
Tapered-cuff Endotracheal Tube Does Not Prevent Early Postoperative Pneumonia Compared with Spherical-cuff Endotracheal Tube after Major Vascular Surgery. Anesthesiology 2016; 124:1041-52. [DOI: 10.1097/aln.0000000000001053] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
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 < 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.
Collapse
|
24
|
Negro MSD, Barreto G, Antonelli RQ, Baldasso TA, Meirelles LRD, Moreira MM, Tincani AJ. Effectiveness of the endotracheal tube cuff on the trachea: physical and mechanical aspects. Braz J Cardiovasc Surg 2015; 29:552-8. [PMID: 25714208 PMCID: PMC4408817 DOI: 10.5935/1678-9741.20140096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 07/24/2014] [Indexed: 11/20/2022] Open
Abstract
Introduction The inflation pressure of the endotracheal tube cuff can cause ischemia of the
tracheal mucosa at high pressures; thus, it can cause important tracheal morbidity
and tracheal microaspiration of the oropharyngeal secretion, or it can even cause
pneumonia associated with mechanical ventilation if the pressure of the cuff is
insufficient. Objective In order to investigate the effectiveness of the RUSCH® 7.5 mm endotracheal tube
cuff, this study was designed to investigate the physical and mechanical aspects
of the cuff in contact with the trachea. Methods For this end, we developed an in vitro experimental model to assess the flow of
dye (methylene blue) by the inflated cuff on the wall of the artificial material.
We also designed an in vivo study with 12 Large White pigs under endotracheal
intubation. We instilled the same dye in the oral cavity of the animals, and we
analyzed the presence or not of leakage in the trachea after the region of the
cuff after their deaths (animal sacrifice). All cuffs were inflated at the
pressure of 30 cmH2O. Results We observed the passage of fluids through the cuff in all in vitro and in vivo
experimental models. Conclusion We conclude that, as well as several other cuff models in the literature, the
RUSCH® 7.5 mm tube cuffs are also not able to completely seal the trachea and thus
prevent aspiration of oropharyngeal secretions. Other prevention measures should
be taken.
Collapse
Affiliation(s)
| | | | | | | | | | - Marcos Mello Moreira
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Alfio José Tincani
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| |
Collapse
|
25
|
|
26
|
Philippart F, Gaudry S, Quinquis L, Lau N, Ouanes I, Touati S, Nguyen JC, Branger C, Faibis F, Mastouri M, Forceville X, Abroug F, Ricard JD, Grabar S, Misset B. Randomized Intubation with Polyurethane or Conical Cuffs to Prevent Pneumonia in Ventilated Patients. Am J Respir Crit Care Med 2015; 191:637-45. [DOI: 10.1164/rccm.201408-1398oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
27
|
Reply to: Adjusting tracheal tube cuff pressure. Eur J Anaesthesiol 2015; 32:281. [PMID: 25599437 DOI: 10.1097/eja.0000000000000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
28
|
Blot SI, Poelaert J, Kollef M. How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients. BMC Infect Dis 2014; 14:119. [PMID: 25430629 PMCID: PMC4289393 DOI: 10.1186/1471-2334-14-119] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 02/28/2014] [Indexed: 12/02/2022] Open
Abstract
Microaspiration of subglottic secretions through channels formed by folds in high volume-low pressure poly-vinyl chloride cuffs of endotracheal tubes is considered a significant pathogenic mechanism of ventilator-associated pneumonia (VAP). Therefore a series of prevention measures target the avoidance of microaspiration. However, although some of these can minimize microaspiration, benefits in terms of VAP prevention are not always obvious. Polyurethane-cuffed endotracheal tubes successfully reduce microaspiration but high quality data demonstrating VAP rate reduction are lacking. An analogous conclusion can be made regarding taper-shaped cuffs compared with classic barrel-shaped cuffs. More clinical data regarding these endotracheal tube designs are needed to demonstrate clinical value in addition to in vitro-based evidence. The clinical usefulness of endotracheal tubes developed for subglottic secretions drainage is established in multiple studies and confirmed by meta-analysis. Any change in cuff design will fail to prevent microaspiration if the cuff is insufficiently inflated. At least one well-designed trial demonstrated that continuous cuff pressure monitoring and control decrease the risk of VAP. Gel lubrication of the cuff prior to intubation temporarily hampers microaspiration through sludging the channels formed by folds in high volume-low pressure cuffs. As the beneficial effect of gel lubrication is temporarily, its potential to reduce VAP risk is probably nonsignificant. A minimum positive end-expiratory pressure of at least 5 cmH2O can be recommended as it reduces the risk of microaspiration in vitro and in vivo. One randomized controlled study demonstrated a reduced risk of VAP in patients ventilated with PEEP (5–8 cmH2O). Regarding head-of-bed elevation, it can be recommended to avoid supine positioning. Whether a 45° head-of-bed elevation is to be preferred above 25-30° head-of-bed elevation remains unproven. Finally, the routine monitoring of gastric residual volumes in mechanically ventilated patients receiving enteral nutrition cannot be recommended.
Collapse
Affiliation(s)
- Stijn I Blot
- Dept, of Internal Medicine, Faculty of Medicine & Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium.
| | | | | |
Collapse
|
29
|
Gravity predominates over ventilatory pattern in the prevention of ventilator-associated pneumonia. Crit Care Med 2014; 42:e620-7. [PMID: 24979484 DOI: 10.1097/ccm.0000000000000487] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In the semirecumbent position, gravity-dependent dissemination of pathogens has been implicated in the pathogenesis of ventilator-associated pneumonia. We compared the preventive effects of a ventilatory strategy, aimed at decreasing pulmonary aspiration and enhancing mucus clearance versus the Trendelenburg position. DESIGN Prospective randomized animal study. SETTING Animal research facility, University of Barcelona, Spain. SUBJECTS Twenty-four Large White-Landrace pigs. INTERVENTIONS Pigs were intubated and on mechanical ventilation for 72 hours. Following surgical preparation, pigs were randomized to be positioned: 1) in semirecumbent/prone position, ventilated with a duty cycle (TITTOT) of 0.33 and without positive end-expiratory pressure (control); 2) as in the control group, positive end-expiratory pressure of 5 cm H2O and TITTOT to achieve a mean expiratory-inspiratory flow bias of 10 L/min (treatment); 3) in Trendelenburg/prone position and ventilated as in the control group (Trendelenburg). Following randomization, Pseudomonas aeruginosa was instilled into the oropharynx. MEASUREMENTS AND MAIN RESULTS Mucus clearance rate was measured through fluoroscopic tracking of tracheal markers. Microspheres were instilled into the subglottic trachea to assess pulmonary aspiration. Ventilator-associated pneumonia was confirmed by histological/microbiological studies. The mean expiratory-inspiratory flow in the treatment, control, and Trendelenburg groups were 10.7 ± 1.7, 1.8 ± 3.7 and 4.3 ± 2.8 L/min, respectively (p < 0.001). Mucus clearance rate was 11.3 ± 9.9 mm/min in the Trendelenburg group versus 0.1 ± 1.0 in the control and 0.2 ± 1.0 in the treatment groups (p = 0.002). In the control group, we recovered 1.35% ± 1.24% of the instilled microspheres per gram of tracheal secretions, whereas 0.22% ± 0.25% and 0.97% ± 1.44% were recovered in the treatment and Trendelenburg groups, respectively (p = 0.031). Ventilator-associated pneumonia developed in 66.67%, 85.71%, and 0% of the animals in the control, treatment, and Trendelenburg groups (p < 0.001). CONCLUSIONS The Trendelenburg position predominates over expiratory flow bias and positive end-expiratory pressure in the prevention of gravity-dependent translocation of oropharyngeal pathogens and development of ventilator-associated pneumonia. These findings further substantiate the primary role of gravity in the pathogenesis of ventilator-associated pneumonia.
Collapse
|
30
|
Randomised controlled trials: are we looking at treatment effects or absence of good clinical practice in control groups? Eur J Anaesthesiol 2014; 31:450-1. [PMID: 25077895 DOI: 10.1097/eja.0000000000000039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
31
|
Fernandez JF, Restrepo MI. Too passive to prevent ventilator-associated pneumonia. Respir Care 2014; 58:1704-6. [PMID: 24064628 DOI: 10.4187/respcare.02803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Juan Felipe Fernandez
- Division of Pulmonary Diseases and Critical CareUniversity of Texas Health Science Centerat San AntonioSan Antonio, Texas
| | | |
Collapse
|
32
|
A Novel Porcine Model of Ventilator-associated Pneumonia Caused by Oropharyngeal Challenge with Pseudomonas aeruginosa. Anesthesiology 2014; 120:1205-15. [DOI: 10.1097/aln.0000000000000222] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
Animal models of ventilator-associated pneumonia (VAP) in primates, sheep, and pigs differ in the underlying pulmonary injury, etiology, bacterial inoculation methods, and time to onset. The most common ovine and porcine models do not reproduce the primary pathogenic mechanism of the disease, through the aspiration of oropharyngeal pathogens, or the most prevalent human etiology. Herein the authors characterize a novel porcine model of VAP due to aspiration of oropharyngeal secretions colonized by Pseudomonas aeruginosa.
Methods:
Ten healthy pigs were intubated, positioned in anti-Trendelenburg, and mechanically ventilated for 72 h. Three animals did not receive bacterial challenge, whereas in seven animals, a P. aeruginosa suspension was instilled into the oropharynx. Tracheal aspirates were cultured and respiratory mechanics were recorded. On autopsy, lobar samples were obtained to corroborate VAP through microbiological and histological studies.
Results:
In animals not challenged, diverse bacterial colonization of the airways was found and monolobar VAP rarely developed. In animals with P. aeruginosa challenge, colonization of tracheal secretion increased up to 6.39 ± 0.34 log colony-forming unit (cfu)/ml (P < 0.001). VAP was confirmed in six of seven pigs, in 78% of the cases developed in the dependent lung segments (right medium and lower lobes, P = 0.032). The static respiratory system elastance worsened to 41.5 ± 5.8 cm H2O/l (P = 0.001).
Conclusions:
The authors devised a VAP model caused by aspiration of oropharyngeal P. aeruginosa, a frequent causative pathogen of human VAP. The model also overcomes the practical and legislative limitations associated with the use of primates. The authors’ model could be employed to study pathophysiologic mechanisms, as well as novel diagnostic/preventive strategies.
Collapse
|
33
|
Insights on the role of antimicrobial cuffed endotracheal tubes in preventing transtracheal transmission of VAP pathogens from an in vitro model of microaspiration and microbial proliferation. BIOMED RESEARCH INTERNATIONAL 2014; 2014:120468. [PMID: 24818125 PMCID: PMC4003835 DOI: 10.1155/2014/120468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 12/12/2013] [Accepted: 03/18/2014] [Indexed: 11/17/2022]
Abstract
We developed an in vitro model to evaluate the effect of different cuffed endotracheal tubes (ETTs) on transtracheal transmission of ventilator-associated pneumonia (VAP) pathogens along external surfaces of ETTs. The model independently assessed the relative contributions of microbial proliferation to the distal tip and microaspiration of contaminated secretions past the cuff by testing in three modes: microaspiration only, microbial proliferation only, and simultaneous microaspiration and microbial proliferation. We evaluated transmission of methicillin resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa (PA) in the presence of a standard ETT; a soft, tapered cuff ETT with subglottic suctioning; and a novel antimicrobial gendine (combination of gentian violet and chlorhexidine) ETT in the model. In the microaspiration only mode, when leakage past the cuff occurred quickly, no ETT prevented transmission. When microaspiration was delayed, the gendine ETT was able to completely disinfect the fluid above the cuff and thereby prevent transmission of pathogens. In microbial proliferation only mode, the gendine ETT was the sole ETT that prevented transmission. With both mechanisms simultaneously available, transmission was dependent on how long microaspiration was delayed. Potent antimicrobial ETTs, such as a gendine ETT, can make unique contributions to prevent VAP when microaspiration is gradual.
Collapse
|
34
|
Oliveira J, Zagalo C, Cavaco-Silva P. Prevention of ventilator-associated pneumonia. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:152-61. [PMID: 24674617 DOI: 10.1016/j.rppneu.2014.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/06/2014] [Accepted: 01/08/2014] [Indexed: 12/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- J Oliveira
- CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal; TechnoPhage S.A., Lisbon, Portugal
| | - C Zagalo
- CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal; Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - P Cavaco-Silva
- CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal; TechnoPhage S.A., Lisbon, Portugal.
| |
Collapse
|
35
|
Dewavrin F, Zerimech F, Boyer A, Maboudou P, Balduyck M, Duhamel A, Nseir S. Accuracy of alpha amylase in diagnosing microaspiration in intubated critically-ill patients. PLoS One 2014; 9:e90851. [PMID: 24603906 PMCID: PMC3946401 DOI: 10.1371/journal.pone.0090851] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 02/04/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Amylase concentration in respiratory secretions was reported to be a potentially useful marker for aspiration and pneumonia. The aim of this study was to determine accuracy of α-amylase in diagnosing microaspiration in critically ill patients. METHODS Retrospective analysis of prospectively collected data collected in a medical ICU. All patients requiring mechanical ventilation for at least 48 h, and included in a previous randomized controlled trial were eligible for this study, provided that at least one tracheal aspirate was available for α-amylase measurement. As part of the initial trial, pepsin was quantitatively measured in all tracheal aspirates during a 48-h period. All tracheal aspirates were frozen, allowing subsequent measurement of α-amylase for the purpose of the current study. Microaspiration was defined as the presence of at least one positive tracheal aspirate for pepsin (>200 ng.mL-1). Abundant microaspiration was defined as the presence of pepsin at significant level in >74% of tracheal aspirates. RESULTS Amylase was measured in 1055 tracheal aspirates, collected from 109 patients. Using mean α-amylase level per patient, accuracy of α-amylase in diagnosing microaspiration was moderate (area under the receiver operator curve 0.72±0.05 [95%CI 0.61-0.83], for an α-amylase value of 1685 UI.L-1). However, when α-amylase levels, coming from all samples, were taken into account, area under the receiver operator curve was 0.56±0.05 [0.53-0.60]. Mean α-amylase level, and percentage of tracheal aspirates positive for α-amylase were significantly higher in patients with microaspiration, and in patients with abundant microaspiration compared with those with no microaspiration; and similar in patients with microaspiration compared with those with abundant microaspiration. α-amylase and pepsin were significantly correlated (r2 = 0.305, p = 0.001). CONCLUSION Accuracy of mean α-amylase in diagnosing microaspiration is moderate. Further, when all α-amylase levels were taken into account, α-amylase was inaccurate in diagnosing microaspiration, compared with pepsin.
Collapse
Affiliation(s)
- Florent Dewavrin
- Intensive Care Unit, Valenciennes Hospital, avenue Desandrouin, Valenciennes, France
| | - Farid Zerimech
- Biochemistry and Molecular Biology Laboratory, Faculty of Pharmacy, Lille II University, Lille, France
| | - Alexandre Boyer
- Medical Intensive Care Unit, CHU Bordeaux, Place Amélie Raba Léon, Bordeaux, France
| | - Patrice Maboudou
- Biochemistry and Molecular Biology Laboratory, Faculty of Pharmacy, Lille II University, Lille, France
| | - Malika Balduyck
- Biochemistry and Molecular Biology Laboratory, Faculty of Pharmacy, Lille II University, Lille, France
| | - Alain Duhamel
- Epidemiology, Public Health and Quality of Care, Nord-de-France University, Lille, France
| | - Saad Nseir
- Critical Care Center, R. Salengro Hospital, University Hospital of Lille, Lille, France
- Medical Assessment Laboratory, EA 2694, University of Lille Nord de France, Lille, France
- * E-mail:
| |
Collapse
|
36
|
Jaillette E, Martin-Loeches I, Artigas A, Nseir S. Optimal care and design of the tracheal cuff in the critically ill patient. Ann Intensive Care 2014; 4:7. [PMID: 24572178 PMCID: PMC3941480 DOI: 10.1186/2110-5820-4-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 02/18/2014] [Indexed: 11/15/2022] Open
Abstract
Despite the increasing use of non-invasive ventilation and high-flow nasal-oxygen therapy, intubation is still performed in a large proportion of critically ill patients. The aim of this narrative review is to discuss recent data on long-term intubation-related complications, such as microaspiration, and tracheal ischemic lesions. These complications are common in critically ill patients, and are associated with substantial morbidity and mortality. Recent data suggest beneficial effects of tapered cuffed tracheal tubes in reducing aspiration. However, clinical data are needed in critically ill patients to confirm this hypothesis. Polyurethane-cuffed tracheal tubes and continuous control of cuff pressure could be beneficial in preventing microaspiration and ventilator-associated pneumonia (VAP). However, large multicenter studies are needed before recommending their routine use. Cuff pressure should be maintained between 20 and 30 cmH2O to prevent intubation-related complications. Tracheal ischemia could be prevented by manual or continuous control of cuff pressure.
Collapse
Affiliation(s)
| | | | | | - Saad Nseir
- Pôle de Réanimation, Hôpital Salengro, CHRU de Lille, Université Nord de France, Lille, France.
| |
Collapse
|
37
|
Grant T. Do current methods for endotracheal tube cuff inflation create pressures above the recommended range? A review of the evidence. J Perioper Pract 2014; 23:292-5. [PMID: 24404708 DOI: 10.1177/175045891302301205] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Inflation and measurement of endotracheal (ET) tube cuff pressure is often not seen as a critical aspect of care in surgical patients. The morbidity associated by an overinflated cuff has been regularly highlighted in literature, for example mucosal ulceration (Combes et al 2001) and vocal cord paralysis (Holley & Gildea 1971). This article will outline techniques for the methods of inflation based on the latest scientific evidence. The author will seek to examine if intraoperative cuff assessment and monitoring should become routine for the anaesthetic practitioner and if current practice for inflating cuffs creates pressures outside the safe range.
Collapse
|
38
|
Grant T. Do current methods for endotracheal tube cuff inflation create pressures above the recommended range? A review of the evidence. J Perioper Pract 2014; 23:198-201. [PMID: 24245362 DOI: 10.1177/175045891302300904] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inflation and measurement of endotracheal (ET) tube cuff pressure is often not seen as a critical aspect of care in surgical patients. The morbidity associated by an overinflated cuff has been regularly highlighted in literature, for example mucosal ulceration (Combes et al 2001) and vocal cord paralysis (Holley & Gildea 1971). This article will outline techniques for the methods of inflation based on the latest scientific evidence. The author will seek to examine if intra-operative cuff assessment and monitoring should become routine for the anaesthetic practitioner and if current practice for inflating cuffs creates pressures outside the safe range.
Collapse
|
39
|
Jaillette E, Zerimech F, De Jonckheere J, Makris D, Balduyck M, Durocher A, Duhamel A, Nseir S. Efficiency of a pneumatic device in controlling cuff pressure of polyurethane-cuffed tracheal tubes: a randomized controlled study. BMC Anesthesiol 2013; 13:50. [PMID: 24369057 PMCID: PMC3877974 DOI: 10.1186/1471-2253-13-50] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 12/18/2013] [Indexed: 11/09/2022] Open
Abstract
Background The primary objective of this study was to determine the efficiency of a pneumatic device in controlling cuff pressure (Pcuff) in patients intubated with polyurethane-cuffed tracheal tubes. Secondary objectives were to determine the impact of continuous control of Pcuff, and cuff shape on microaspiration of gastric contents. Methods Prospective randomized controlled study. All patients requiring intubation and mechanical ventilation ≥48 h were eligible. The first 32 patients were intubated with tapered polyurethane-cuffed, and the 32 following patients were intubated with cylindrical polyurethane-cuffed tracheal tubes. Patients randomly received 24 h of continuous control of Pcuff using a pneumatic device (Nosten®), and 24 h of routine care of Pcuff using a manometer. Target Pcuff was 25 cmH2O. Pcuff was continuously recorded, and pepsin was quantitatively measured in all tracheal aspirates during these periods. Results The pneumatic device was efficient in controlling Pcuff (med [IQ] 26 [24, 28] vs 22 [20, 28] cmH2O, during continuous control of Pcuff and routine care, respectively; p = 0.017). In addition, percentage of patients with underinflation (31% vs 68%) or overinflation (53% vs 100%) of tracheal cuff, and percentage of time spent with underinflation (0.9 [0, 17] vs 14% [4, 30]) or overinflation (0 [0, 2] vs 32% [9, 54]) were significantly (p < 0.001) reduced during continuous control of Pcuff compared with routine care. No significant difference was found in microaspiration of gastric content between continuous control of Pcuff compared with routine care, or between patients intubated with tapered compared with cylindrical polyurethane-cuffed tracheal tubes. Conclusion The pneumatic device was efficient in controlling Pcuff in critically ill patients intubated with polyurethane-cuffed tracheal tubes. Trial registration The Australian New Zealand Clinical Trials Registry (NCT01351259)
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Saad Nseir
- Critical Care Center, R, Salengro Hospital, University Hospital of Lille, Rue E, Laine, 59037 Lille cedex, France.
| |
Collapse
|
40
|
Kanotra SP, Propst EJ, Luginbuehl I, Campisi P, Fisher JA, Forte V. Assessment of aspiration risk from dynamic modulation of endotracheal tube cuff pressure. Laryngoscope 2013; 124:1415-9. [PMID: 24155094 DOI: 10.1002/lary.24481] [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: 05/30/2013] [Revised: 09/28/2013] [Accepted: 10/21/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess the risk of aspiration using a novel valve circuit that dynamically modulates endotracheal tube cuff pressure during the ventilatory cycle using bench and live animal models. STUDY DESIGN Animal model. METHODS The bench model consisted of a cuffed endotracheal tube inserted into an artificial trachea. Leakage of liquid around the cuff was measured after 4 hours of constant or dynamic modulation of cuff pressure at variable peak end expiratory pressures. In the porcine model, eight animals were ventilated with the modulating valve circuit and compared to eight controls ventilated with a constant cuff pressure (25 cm of water). Aspiration was monitored quantitatively using a pH probe (measured as voltage) and visually using fluoroscopy. RESULTS There was no difference in the amount of fluid leakage around the endotracheal tube cuff in the constant or dynamically modulated pressure-cuff groups in the bench or animal models. CONCLUSION Dynamically modulating endotracheal tube-cuff pressures to minimize tracheal mucosal damage does not increase the tendency to leak around the cuff compared to endotracheal tube cuffs inflated to a constant pressure. LEVEL OF EVIDENCE N/A.
Collapse
Affiliation(s)
- Sohit P Kanotra
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | | | | | | | | | | |
Collapse
|
41
|
D'HAESE J, DE KEUKELEIRE T, REMORY I, VAN ROMPAEY K, UMBRAIN V, POELAERT J. Assessment of intraoperative microaspiration: does a modified cuff shape improve sealing? Acta Anaesthesiol Scand 2013; 57:873-80. [PMID: 23556486 DOI: 10.1111/aas.12119] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intra-operative aspiration of oropharyngeal secretions is associated with post-operative pneumonia. The use of endotracheal tubes (ETTs) with a modified cuff shape could be one preventive action. In this clinical, prospective, randomised controlled trial, we hypothesised that altering the cuff shape to a tapered shape could reduce the aspiration incidence. The primary outcome was aspiration of dye solution into the trachea. METHODS Patients scheduled for lumbar surgery were intubated with either an ETT with a barrel-shaped polyvinylchloride cuff (control group, n = 30) or tapered-shaped polyvinylchloride cuff (intervention group, n = 30). Subsequently, instillation with methylthioninium chloride was performed. At 10, 30, 60, 90, and 120 min after intubation, bronchoscopy was performed assessing the degree of dye descent along the cuff and digitally stored. Single blind review of the videoclips provided data on incidence of dye aspiration and depth of penetration along the cuff. RESULTS The traditional cuff showed descent of dye into the trachea in 20% of the patients. Although a tapered-shaped polyvinylchloride cuff leaked up to the second third of the cuff, no dye leakage into the trachea was observed. The use of a tapered-shaped cuff had a protective role against aspiration (T30: OR 3.0, CI 1.57-5.75; P = 0.001). CONCLUSIONS Short-term use of tapered-shaped polyvinylchloride cuffs in surgical patients results in more effective sealing of the tracheal lumen in comparison with a traditional barrel-shaped polyvinylchloride cuffs. Further evaluation is needed to determine whether a reduction in post-operative pneumonia can be demonstrated when these cuffs are used.
Collapse
Affiliation(s)
- J. D'HAESE
- Department of Anaesthesiology and Perioperative Medicine; Pneumology and Neurosurgery; University Hospital; Brussels; Belgium
| | - T. DE KEUKELEIRE
- Department of Anaesthesiology and Perioperative Medicine; Pneumology and Neurosurgery; University Hospital; Brussels; Belgium
| | - I. REMORY
- Department of Anaesthesiology and Perioperative Medicine; Pneumology and Neurosurgery; University Hospital; Brussels; Belgium
| | - K. VAN ROMPAEY
- Department of Anaesthesiology and Perioperative Medicine; Pneumology and Neurosurgery; University Hospital; Brussels; Belgium
| | - V. UMBRAIN
- Department of Anaesthesiology and Perioperative Medicine; Pneumology and Neurosurgery; University Hospital; Brussels; Belgium
| | - J. POELAERT
- Department of Anaesthesiology and Perioperative Medicine; Pneumology and Neurosurgery; University Hospital; Brussels; Belgium
| |
Collapse
|
42
|
Hwang JY, Han SH, Park SH, Park SJ, Park S, Oh SH, Kim JH. Interrupting gel layer between Double cuffs prevents fluid leakage past tracheal tube cuffs. Br J Anaesth 2013; 111:496-504. [PMID: 23670722 DOI: 10.1093/bja/aet152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Current tracheal tubes (TTs) cannot guarantee a perfect seal against pulmonary aspiration of upper airway secretions. The purpose of this study was to investigate whether a gel layer between the tracheal tube with double cuffs (Double cuffs) prevents fluid leakage past TT cuffs. METHODS In vitro fluid leakage tests were performed using the Double cuff with or without a gel layer between the two cuffs and four commercially available TTs (Euromedical Standard TT, Mallinckrodt Hi-Lo™, Microcuff, and Mallinckrodt TaperGuard™) when placed in artificial tracheas with three-different internal diameters (ID; 16, 20, and 22 mm). Blue-dyed water (5 ml) was placed above the cuff, and the extent of fluid leakage was observed for 48 h. Each test was repeated five times with new tubes at six different intracuff pressures (15, 20, 25, 30, 40, and 50 cm H2O). RESULTS In all of the conventional TTs and the Double cuff without a gel layer, fluid leakage was observed even at clinically acceptable intracuff pressures (25-30 cm H2O). However, in the Double cuff with a gel layer, no fluid leakage was observed for 48 h at all intracuff pressures in three-different sized artificial tracheas. At an intracuff pressure of 20 cm H2O in a 20 mm ID trachea, the average volume of injected gel was 2.0 ml. After removal of the TT, the mean volume of the remaining gel in the trachea was 0.10 ml. CONCLUSIONS A prototype TT with gel-layered Double cuffs completely blocked fluid leakage past the cuffs for 48 h in a bench-top model. Clinical studies are required to determine whether this TT reduces the risk of ventilator-associated pneumonia.
Collapse
Affiliation(s)
- J Y Hwang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | | | | | | | | | | | | |
Collapse
|
43
|
An in vitro study to assess determinant features associated with fluid sealing in the design of endotracheal tube cuffs and exerted tracheal pressures. Crit Care Med 2013; 41:518-26. [PMID: 23263575 DOI: 10.1097/ccm.0b013e31826a4804] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the structural characteristics involved in the design of high-volume low-pressure endotracheal tube cuffs that are associated with fluid sealing effectiveness and to determine the extent of transmitted tracheal pressures upon cuff inflation. DESIGN In vitro study. SETTINGS Pneumology laboratories. INTERVENTIONS Eight high-volume low-pressure cuffs of cylindrical or tapered shape, made of polyvinylchloride or polyurethane, were studied. Cuffs were tested within a tracheal model, oriented 30° above horizontal to assess 1 hr leakage of oropharyngeal secretions simulant at cuff internal pressures of 15-30 cm H2O. The four best performing cuffs were evaluated for 24 hrs using an internal pressure of 30 cm H2O. The extent of transmitted tracheal wall pressure throughout the cuff-trachea contact area was determined using an internal pressure sensor within a tracheal model upon cuff inflation up to 30 cm H2O. MEASUREMENTS AND MAIN RESULTS Outer diameter, length, and compliance of each cuff were assessed. Multivariate regression analysis was performed to identify the main determinants of simulant leakage rate. The cuff-trachea contact area and the percentage of tracheal wall pressure measurements greater than 50 cm H2O were computed. Cuff design characteristics significantly differ among tubes. The cuffs made of polyurethane showed the best short- and long-term sealing efficacy. Nevertheless, in the multivariate analysis, the cuff outer diameter (n: 288, p = 0.003) and length (n: 288, p < 0.001), along with the internal pressure (n: 288, p < 0.001), were the only predictors of simulant leakage rate. The tapered cuffs showed the lowest tracheal wall contact area (n: 96, p < 0.001). The tracheal wall pressure distribution pattern was heterogeneous, and the percentage of high tracheal wall pressure significantly differs among the cuffs (n: 96, p < 0.001). CONCLUSIONS The high-volume low-pressure cuffs' outer diameter, length, material, and internal pressure are the main determinants of sealing efficacy. Despite internal pressure within the safe range, transmitted tracheal pressure is extremely heterogeneous and differs among cuffs, occasionally reaching localized, very high, unsafe levels.
Collapse
|
44
|
Beuret P, Philippon B, Fabre X, Kaaki M. Effect of tracheal suctioning on aspiration past the tracheal tube cuff in mechanically ventilated patients. Ann Intensive Care 2012; 2:45. [PMID: 23134813 PMCID: PMC3520779 DOI: 10.1186/2110-5820-2-45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 10/22/2012] [Indexed: 11/22/2022] Open
Abstract
Background This clinical study evaluated the effect of a suctioning maneuver on aspiration past the cuff during mechanical ventilation. Methods Patients intubated for less than 48 hours with a PVC-cuffed tracheal tube, under mechanical ventilation with a PEEP ≥5 cm H2O and under continuous sedation, were included in the study. At baseline the cuff pressure was set at 30 cm H2O. Then 0.5ml of blue dye diluted with 3 ml of saline was instilled into the subglottic space just above the cuff. Tracheal suctioning was performed using a 16-French suction catheter with a suction pressure of – 400 mbar. A fiberoptic bronchoscopy was performed before and after the suctioning maneuver, looking for the presence of blue dye in the folds within the cuff wall or in the trachea under the cuff. The sealing of the cuff was defined by the absence of leakage of blue dye either in the cuff wall or in the trachea under the cuff. Results Twenty-five patients were included. The size of the tracheal tube was 7-mm ID for 5 patients, 7.5-mm ID for 16 patients, and 8-mm ID for four patients. Blue dye was never seen in the trachea under the cuff before suctioning and only in one patient (4%) after the suctioning maneuver. Blue dye was observed in the folds within the cuff wall in 6 of 25 patients before suctioning and 11 of 25 after (p = 0.063). Overall, the incidence of sealing of the cuff was 76% before suctioning and 56% after (p = 0.073). Conclusions In patients intubated with a PVC-cuffed tracheal tube and under mechanical ventilation with PEEP ≥5 cm H2O and a cuff pressure set at 30 cm H2O, a single tracheal suctioning maneuver did not increase the risk of aspiration in the trachea under the cuff. Trial registration ClinicalTrials.gov, number NCT01170156
Collapse
Affiliation(s)
- Pascal Beuret
- Intensive Care Unit, Centre Hospitalier Roanne, 28 rue de Charlieu, 42328, Roanne, France.
| | | | | | | |
Collapse
|
45
|
Fernandez JF, Levine SM, Restrepo MI. Technologic advances in endotracheal tubes for prevention of ventilator-associated pneumonia. Chest 2012; 142:231-238. [PMID: 22796845 DOI: 10.1378/chest.11-2420] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Juan F Fernandez
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, the University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Stephanie M Levine
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, the University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Marcos I Restrepo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, the University of Texas Health Science Center at San Antonio, San Antonio, TX; Veterans Evidence Based Research Dissemination and Implementation Center (VERDICT), Audie L. Murphy VA Hospital, San Antonio, TX.
| |
Collapse
|
46
|
Abstract
Ventilator-associated pneumonia (VAP) is the most frequent and severe infection acquired in the intensive care unit, leading to prolonged mechanical ventilation and excess mortality. This article reviews the different aspects of VAP, such as risk factors, causative agents, and approaches to diagnosis, treatment, and prevention. Several aspects of VAP are still considered controversial.
Collapse
Affiliation(s)
- Jean-Louis Trouillet
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris 6-Pierre et Marie Curie, Paris, France.
| |
Collapse
|
47
|
Abstract
PURPOSE OF REVIEW Endotracheal intubation and mechanical ventilation are lifesaving measures in critically ill patients. However, these interventions increase the risk of respiratory infections, particularly ventilator-associated pneumonia (VAP). VAP constitutes a serious burden for the healthcare system and worsens the patient's outcomes; thus, several preventive strategies have been implemented. This communication reviews the current knowledge on VAP pathogenesis and the latest preventive measures. RECENT FINDINGS Pathogen-laden oropharyngeal secretions leak across the endotracheal tube (ETT) cuff; thus, a continuous control of the internal cuff pressure and cuffs made of polyurethane improve sealing effectiveness and associated risks of infections. Subglottic secretions aspiration prevents VAP, and the latest evidence demonstrated a reduction in the incidence of late-onset VAP. The role of ETT biofilm in the pathogenesis of VAP is not fully elucidated. Nevertheless, antimicrobial-coated ETTs have showed beneficial effects in VAP incidence. Recent experimental evidence has challenged the benefits associated with the use of the semirecumbent position; yet, these findings need to be corroborated in clinical trials. The latest results from trials testing the effects of selective digestive decontamination (SDD) showed beneficial effects on patients' outcomes, but concerns remain regarding the emergence of bacterial resistance, specifically upon digestive tract re-colonization. The use of oropharyngeal decontamination with antiseptics and the use of probiotics are potential alternatives to SDD. SUMMARY There is consistent evidence that strategies affecting the primary mechanisms of VAP pathogenesis efficiently reduce the occurrence of the disease. Preventive measures should be implemented grouped into bundles to improve overall efficacy.
Collapse
|
48
|
MADJDPOUR C, MAUCH J, DAVE MH, SPIELMANN N, WEISS M. Comparison of air-sealing characteristics of tapered- vs. cylindrical-shaped high-volume, low-pressure tube cuffs. Acta Anaesthesiol Scand 2012; 56:230-5. [PMID: 22091784 DOI: 10.1111/j.1399-6576.2011.02542.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2011] [Indexed: 12/29/2022]
Abstract
BACKGROUND This study aimed at comparing air-sealing characteristics of the new tapered-shaped tracheal tube cuffs with cylindrical tube cuffs. METHODS Tracheal tubes with tapered-shaped polyurethane (PU) and polyvinyl chloride (PVC) cuffs as well as standard cylindrical-shaped cuffs made of PU and PVC (Covidien, Athlone, Ireland) were investigated. A tracheal model attached to a test lung was intubated, and cuffs were inflated to 10, 15, 20, 25 and 30 cm H(2)O. The test lung was ventilated with intermittent positive pressure ventilation at peak inspiratory pressures (PIPs) of 20 and 25 cm H(2)O. Air leakage was assessed by spirometry and measurement of sevoflurane concentration passing the cuff at the upper cuff border using an anaesthetic gas analyser. Experiments were repeated four times with new tracheal tubes for each run. Statistical comparisons were done using Mann-Whitney U-test with level of significance at P < 0.05. RESULTS The tapered-shaped PVC tube cuff demonstrated a significantly lower air leakage determined by spirometry than the cylindrical-shaped cuff at both PIPs (20 and 25 cm H(2)O). Similarly, sevoflurane leakage was less with the tapered PVC cuff particularly at higher cuff pressures. With the PU cuff, reduction in air leakage by a tapered-shaped compared with a cylindrical-shaped tube cuff was not significant. CONCLUSIONS A tapered-shaped tube cuff considerably improves air-sealing characteristics of PVC tube cuffs and allows thereby reducing cuff pressure required for sufficient ventilation. In tube cuffs made of PU that exhibits superior sealing characteristics compared with PVC, a tapered shape failed to result in a further reduction of air leakage.
Collapse
Affiliation(s)
- C. MADJDPOUR
- Department of Anaesthesia; University Children's Hospital Zurich; Zurich; Switzerland
| | - J. MAUCH
- Department of Anaesthesia; University Children's Hospital Zurich; Zurich; Switzerland
| | - M. H. DAVE
- Department of Anaesthesia; University Children's Hospital Zurich; Zurich; Switzerland
| | - N. SPIELMANN
- Department of Anaesthesia; University Children's Hospital Zurich; Zurich; Switzerland
| | - M. WEISS
- Department of Anaesthesia; University Children's Hospital Zurich; Zurich; Switzerland
| |
Collapse
|
49
|
New tracheal tubes to prevent ventilator-associated pneumonia: where is the evidence? Crit Care 2011; 15:459; author reply 459. [PMID: 22152104 PMCID: PMC3388681 DOI: 10.1186/cc10557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
50
|
Zolfaghari PS, Wyncoll DLA. The tracheal tube: gateway to ventilator-associated pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:310. [PMID: 21996487 PMCID: PMC3334734 DOI: 10.1186/cc10352] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a major healthcare-associated complication with considerable attributable morbidity, mortality and cost. Inherent design flaws in the standard high-volume low-pressure cuffed tracheal tubes form a major part of the pathogenic mechanism causing VAP. The formation of folds in the inflated cuff leads to microaspiration of pooled oropharyngeal secretions into the trachea, and biofilm formation on the inner surface of the tracheal tube helps to maintain bacterial colonization of the lower airways. Improved design of tracheal tubes with new cuff material and shape have reduced the size and number of these folds, which together with the addition of suction ports above the cuff to drain pooled subglottic secretions leads to reduced aspiration of oropharyngeal secretions. Furthermore, coating tracheal tubes with antibacterial agents reduces biofilm formation and the incidence of VAP. In this Viewpoint article we explore the published data supporting the new tracheal tubes and their potential contribution to VAP prevention strategies. We also propose that it may now be against good medical practice to continue to use a 'standard cuffed tube' given what is already known, and the weight of evidence supporting the use of newer tube designs.
Collapse
Affiliation(s)
- Parjam S Zolfaghari
- London Deanery, Guy's and St Thomas' NHS Trust, Lambeth Palace Road, London SE1 7EH, UK.
| | | |
Collapse
|