Effectiveness of Continuous Cuff Pressure Control in Preventing Ventilator-Associated Pneumonia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Preventing ventilator-associated pneumonia: A position paper of the International Society for Infectious Diseases, 2024 update

OBJECTIVES

This review by a panel of experts convened by the International Society for Infectious Diseases aims to consolidate current recommendations for preventing ventilator-associated pneumonia (VAP). It provides insights into VAP rates, the attributable extra length of stay, costs, mortality, and risk factors in high-income and low- and middle-income countries (LMICs).

METHODS

A comprehensive review of existing recommendations and evidence-based strategies for preventing VAP was conducted. The expert panel analyzed data on VAP incidence, associated healthcare burdens, and risk factors across different economic settings to formulate applicable preventive measures.

RESULTS

The review identifies significant differences in VAP rates, healthcare costs, extra length of hospital stay, and mortality between high-income and LMICs. Evidence-based strategies for preventing VAP were highlighted, demonstrating their effectiveness across different healthcare settings.

CONCLUSION

The recommendations and insights provided in this position paper aim to guide healthcare professionals in effectively preventing VAP. The adoption of evidence-based preventive strategies can potentially reduce VAP rates, and associated costs, and improve patient outcomes in both high-income and LMICs.

Stepwise implementation of prevention strategies and their impact on ventilator-associated pneumonia incidence: A 13-Year observational surveillance study

OBJECTIVE

To describe the practice of ventilator-associated pneumonia (VAP) prevention and control through the incremental introduction of prevention strategies and assess the effect on VAP incidence.

DESIGN

Historical observational surveillance study conducted over 13 years.

SETTING

A 12-bed adult intensive care unit (ICU) in a general hospital in Belgium.

PARTICIPANTS

Patients admitted between 2007 and 2019, with ICU stays of ≥48 h.

INTERVENTIONS

Incremental introduction of VAP preventive measures from 2008, including head-of-bed elevation, cuff pressure control, endotracheal tubes with tapered cuffs, subglottic secretion drainage, chlorhexidine oral care, and daily sedation assessment.

MEASUREMENTS AND MAIN RESULTS

A significant decline in VAP incidence density rates was observed, from 18.3 to 2.6 cases per 1000 ventilator days from the baseline to the final period.

CONCLUSIONS

Systematic implementation of VAP preventive measures significantly reduced VAP incidence. However, this reduction did not translate into decreased overall ICU mortality.

IMPLICATIONS FOR PRACTICE

The study underscores the importance of continuous VAP surveillance and preventive measures in reducing VAP incidence.

Executive Summary of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management

The Airway section of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) present the Guidelines for the integral management of difficult airway in adult patients. This document provides recommendations based on current scientific evidence, theoretical-educational tools and implementation tools, mainly cognitive aids, applicable to the treatment of the airway in the field of anesthesiology, critical care, emergencies and prehospital medicine. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations and optimization in the progression of the application of strategies to preserve adequate alveolar oxygenation in order to improve safety and quality of care.

The Effect of Perceptions of Evidence-Based Practice on Endotracheal Cuff Pressure Management in Critical Care Nurses: A Correlational Cross-Sectional Multicentre Study

AIMS

This correlational cross-sectional multicentre study aims to achieve two objectives. Firstly, to assess nurses' knowledge and practice of endotracheal cuff pressure management. Secondly, to examine the relationship between endotracheal cuff pressure management knowledge and evidence-based practice leadership and work environment.

DESIGN

A correlational cross-sectional multicentre study design.

METHODS

This study was conducted among 144 intensive care nurses in Turkey. Data collection included descriptive characteristics and cuff pressure management of nurses, the Evidence-Based Practice Leadership Scale and Evidence-Based Practice Work Environment Scale. Descriptive statistics, chi-square test, Pearson correlation and receiver operating characteristics analysis were conducted. A STROBE checklist was the reporting guide for this study.

RESULTS

The success status of nurses in terms of knowledge related to cuff pressure was found significantly different according to the type of intensive care unit working in and the status of receiving training on evidence-based practice. A positive, strong relationship was found between nurses' mean scores on the Evidence-Based Practice Leadership Scale and the Work Environment Scale. There was a very weak positive correlation between the mean scores of the Evidence-Based Practice Leadership Scale and the cuff pressure management.

CONCLUSION

Adherence by nurses to current evidence-based practice for cuff pressure monitoring is essential for safe patient care and improved quality of care. It is recommended to provide both a supportive working environment and training programmes for intensive care nurses to perform cuff pressure management in line with evidence-based practice.

RELEVANCE TO CLINICAL PRACTICE

Providing educational programs, an appropriate clinical environment, support from health managers and access to appropriate tools are important considerations in increasing the knowledge and skills of intensive care nurses to effectively monitor and manage cuff pressure.

REPORTING METHOD

Our study complies with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Checklist: cross-sectional studies.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Continuous cuff pressure control on middle-aged and elderly patients undergoing endoscopic submucosal dissection of the esophagus effect of airway injury

OBJECTIVE

Assessment of the effect of continuous cuff pressure control on airway injury in middle-aged and elderly patients undergoing endoscopic submucosal dissection (ESD).

METHOD

A total of 104 eligible middle-aged and elderly patients requiring esophageal ESD from July 2022-September 2023 at the First Affiliated Hospital of Nanchang University were selected and randomly divided into two groups: the group undergoing general anesthesia tracheal intubation with continuous control of cuff pressure after intubation (Group A, n = 51) and the group undergoing general anesthesia tracheal intubation with continuous monitoring without control of cuff pressure (Group B, n = 53). After endotracheal intubation in Group A, under the guidance of an automatic cuff pressure controller, the air was used to inflate the tracheal cuff until the cuff pressure was 25-30cmH2O. The cuff pressure after intubation was recorded, and then the cuff pressure parameters were directly adjusted in the range of 25-30cmH2O until tracheal extubation after the operation. After endotracheal intubation, patients in Group B inflated the tracheal cuff with clinical experience, then monitored and recorded the cuff pressure with a handheld cuff manometer and instructed the cuff not to be loosened after being connected to the handheld cuff manometer-continuous monitoring until the tracheal extubation, but without any cuff pressure regulation. The patients of the two groups performed esophageal ESD. The left recumbent position was taken before the operation, and the cuff's pressure was recorded. Then, insert the gastrointestinal endoscope to find the lesion site and perform appropriate CO2 inflation to display the diseased esophageal wall for surgical operation fully. After determining the location, the cuff pressure of the two groups was recorded when the cuff pressure was stable. After the operation, the upper gastrointestinal endoscope was removed and the cuff pressure of the two groups was recorded. Postoperative airway injury assessment was performed in both groups, and the incidence of sore throat, hoarseness, cough, and blood in sputum was recorded. The incidence of postoperative airway mucosal injury was also observed and recorded in both groups: typical, episodic congestion spots and patchy local congestion.

RESULT

The incidence of normal airway mucosa in Group A was higher than that in Group B (P < 0.05). In comparison, the incidence of occasional hyperemia and local plaque congestion in Group A was lower than in Group B (P < 0.05).

CONCLUSION

Continuous cuff pressure control during operation can reduce airway injury in patients with esophageal ESD and accelerate their early recovery after the operation.

Continuous Versus Intermittent Control Cuff Pressure for Preventing Ventilator-Associated Pneumonia: An Updated Meta-Analysis

OBJECTIVE

This study aimed to evaluate the effect of continuous control cuff pressure (CCCP) versus intermittent control cuff pressure (ICCP) for the prevention of ventilator-associated pneumonia (VAP) in critically ill patients.

METHODS

Relevant literature was searched in several databases, including PubMed, Embase, Web of Science, ProQuest, the Cochrane Library, Wanfang Database and China National Knowledge Infrastructure between inception and September 2022. Randomized controlled trials were considered eligible if they compared CCCP with ICCP for the prevention of VAP in critically ill patients. This meta-analysis was performed using the RevMan 5.3 and Trial Sequential Analysis 0.9 software packages. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the level of evidence.

RESULTS

We identified 14 randomized control trials with a total of 2080 patients. Meta-analysis revealed that CCCP was associated with a significantly lower incidence of VAP compared with ICCP (relative risk [RR] = 0.52; 95% confidence interval [CI]: 0.37-0.74; P < 0.001), although considerable heterogeneity was observed (I2 = 71%). Conducting trial sequential analysis confirmed the finding, and the GRADE level was moderate. Subgroup analysis demonstrated that CCCP combined with subglottic secretion drainage (SSD) had a more significant effect on reducing VAP (RR = 0.39; 95% CI = 0.29-0.52; P < 0.001). The effect of CCCP on ventilator-associated respiratory infection (VARI) incidence was uncertain (RR = 0.81; 95% CI = 0.53-1.24; P = 0.34; I2 = 61%). Additionally, CCCP significantly reduced the duration of mechanical ventilation (MV) (mean difference [MD] = -2.42 days; 95% CI = -4.71-0.12; P = 0.04; I2 = 87%). Descriptive analysis showed that CCCP improved the qualified rate of cuff pressure. However, no significant differences were found in the length of intensive care unit (ICU) stay (MD = 2.42 days; 95% CI = -1.84-6.68; P = 0.27) and ICU mortality (RR = 0.86; 95% CI = 0.74-1.00; P = 0.05).

CONCLUSION

Our findings suggest that the combination of CCCP and SSD can reduce the incidence of VAP and the duration of MV and maintain the stability of cuff pressure. A combination of CCCP and SSD applications is suggested for preventing VAP.

A Review of Chlorhexidine Oral Care in Patients Receiving Mechanical Ventilation

BACKGROUND

Chlorhexidine gluconate has been considered the criterion standard of oral care for patients receiving mechanical ventilation because of its ability to reduce the incidence of ventilator-associated events. Optimal concentrations and frequencies remain unclear, as do adverse events related to mortality in various intensive care unit populations.

OBJECTIVE

To examine the current evidence for the efficacy of chlorhexidine gluconate in reducing the incidence of ventilator-associated events, mortality, intensive care unit length of stay, and duration of mechanical ventilation in patients receiving ventilator support.

METHODS

In this integrative review, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and Health Source: Nursing/Academic Edition were searched using terms related to mechanical ventilation and chlorhexidine gluconate oral care with dates ranging from 2012 to 2023.

RESULTS

Seventeen articles were included in this review: 8 systematic reviews, 8 randomized clinical trials (3 of which were not included in any systematic review), and 1 quasi-experimental study. Chlorhexidine gluconate oral care was associated with a reduced incidence of ventilator-associated events, but efficacy depended on concentration and frequency of administration. With stratification by intensive care unit population type, a nonsignificant trend toward increased mortality was found among non-cardiac surgical patients who received this care.

CONCLUSION

The evidence regarding the efficacy of chlorhexidine gluconate oral care in reducing ventilator-associated events in specific intensive care unit populations is contradictory. Recently published guidelines recommend de-implementation of chlorhexidine gluconate oral care in all patients receiving mechanical ventilation. Such care may be beneficial only in the cardiac surgical population.

Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events

INTRODUCTION

Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP.

AREAS COVERED

This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles.

EXPERT OPINION

Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Efficacy of preventive interventions against ventilator-associated pneumonia in critically ill patients: an umbrella review of meta-analyses

Many meta-analyses have assessed the efficacy of preventive interventions against ventilator-associated pneumonia (VAP) in critically ill patients. However, there has been no comprehensive analysis of the strength and quality of evidence to date. Systematic reviews of randomized and quasi-randomized controlled trials, which evaluated the effect of preventive strategies on the incidence of VAP in critically ill patients receiving mechanical ventilation for at least 48 h, were included in this article. We identified a total of 34 interventions derived from 31 studies. Among these interventions, 19 resulted in a significantly reduced incidence of VAP. Among numerous strategies, only selective decontamination of the digestive tract (SDD) was supported by highly suggestive (Class II) evidence (risk ratio (RR)=0.439, 95% CI: 0.362-0.532). Based on data from the sensitivity analysis, the evidence for the efficacy of non-invasive ventilation in weaning from mechanical ventilation (NIV) was upgraded from weak (Class IV) to highly suggestive (Class II) (RR=0.32, 95% CI: 0.22-0.46). All preventive interventions were not supported by robust evidence for reducing mortality. Early mobilization exhibited suggestive (Class III) evidence in shortening both intensive length of stay (LOS) in the intensive care unit (ICU) (mean difference (MD)=-0.85, 95% CI: -1.21 to -0.49) and duration of mechanical ventilation (MD=-1.02, 95% CI: -1.41 to -0.63). In conclusion, SDD and NIV are supported by robust evidence for prevention against VAP, while early mobilization has been shown to significantly shorten the LOS in the ICU and the duration of mechanical ventilation. These three strategies are recommendable for inclusion in the ventilator bundle to lower the risk of VAP and improve the prognosis of critically ill patients.

Effects of preoperative oral care on bacterial colonisation and halitosis in patients undergoing elective surgery: A randomised controlled study

OBJECTIVES

To evaluate the effects of single-dose chlorhexidine oral care on bacterial colonisation and halitosis in patients undergoing elective surgery.

RESEARCH METHODOLOGY

We conducted a two-arm parallel, single-blinded, randomised controlled trial. The intervention group (n = 102) received preoperative oral care with 0.12% chlorhexidine gluconate, and the control group (n = 105) received standard care. The data of the microbiological cultures between the groups were compared at the time of tracheal intubation, at extubation and 30 min after surgery. The presence of halitosis was measured using a survey questionnaire administered to the anaesthesia nurses assigned to the patients.

RESULTS

At baseline, no significant differences were found between the intervention and control groups for bacterial colonisation or halitosis. After the intervention, there was no significant difference in microbiological culture, including gram-positive, gram-negative bacilli and cocci results, between the two groups (p > 0.05). The presence of halitosis in the intervention group was significantly lower than in the control group during intubation (p < 0.0001) and at 30 min after surgery (p < 0.02). Regression analysis indicated that receiving oral was protective towards halitosis, while poor oral health was a risk factor.

CONCLUSIONS

Preoperative oral care using a single dose of chlorhexidine significantly improved the patients' halitosis in the perioperative period, but no significant effect was found on bacterial colonisation. Further studies are needed regarding the safe use of chlorhexidine for oral care.

IMPLICATION FOR CLINICAL PRACTICE

Oral hygiene using chlorhexidine could be beneficial in improving halitosis for anaesthesia personnel who take care of intubated adult patients undergoing elective surgery with general anaesthesia.

Benefits and harms of normal saline instillation before endotracheal suctioning in mechanically ventilated adult patients in intensive care units: A systematic literature review and meta-analysis

OBJECTIVES

This systematic review aimed to identify the effects of normal saline instillation before endotracheal suctioning on clinical outcomes in critically ill patients on a mechanical ventilator.

RESEARCH METHODOLOGY

This review was based on the guidelines of the National Evidence-based Healthcare Collaborating Agency in Korea and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Six electronic databases were searched for relevant literature. Other sources were also searched, including the reference lists of identified reports and previous systematic reviews. After the initial literature search, a two-step retrieval process was performed to select eligible studies. Then, data were collected using a newly developed form, and the risk of bias was assessed using the checklists of the Joanna Briggs Institute. Data were analyzed using both narrative syntheses and meta-analyses.

RESULTS

In total, 16 studies: 13 randomized controlled trials and three quasi-experimental studies, were included. From the narrative syntheses, instilling normal saline before endotracheal suctioning was associated with a decrease in oxygen saturation, prolonged time for oxygen saturation to recover to baseline, decreased arterial pH, increased secretion amount, reduced incidence of ventilator-associated pneumonia, increased heart rate, and increased systolic blood pressure. Meta-analyses showed a significant difference in heart rate at five minutes after suctioning but no significant differences in oxygen saturation at two and five minutes after suctioning and heart rate at two minutes after suctioning.

CONCLUSION

This systematic review indicated that instilling normal saline before performing endotracheal suctioning has more harmful effects than benefits.

IMPLICATIONS FOR CLINICAL PRACTICE

As recommended in the current guidelines, it is necessary to refrain from routine normal saline instillation before endotracheal suctioning.

Clinical Features and Outcomes of VAP Due to Multidrug-Resistant Klebsiella spp.: A Retrospective Study Comparing Monobacterial and Polybacterial Episodes

VAP due to multidrug-resistant (MDR) bacteria is a frequent infection among patients in ICUs. Patient characteristics and mortality in mono- and polybacterial cases of VAP may differ. A single-centre, retrospective 3-year study was conducted in the four ICUs of a Lithuanian referral university hospital, aiming to compare both the clinical features and the 60-day ICU all-cause mortality of monobacterial and polybacterial MDR Klebsiella spp. VAP episodes. Of the 86 MDR Klebsiella spp. VAP episodes analyzed, 50 (58.1%) were polybacterial. The 60-day mortality was higher (p < 0.05) in polybacterial episodes: overall (50.0 vs. 27.8%), in the sub-group with less-severe disease (SOFA < 8) at VAP onset (45.5 vs. 15.0%), even with appropriate treatment (41.7 vs. 12.5%), and the sub-group of extended drug-resistant (XDR) Klebsiella spp. (46.4 vs. 17.6%). The ICU mortality (44.0 vs. 22.5%) was also higher in the polybacterial episodes. The monobacterial MDR Klebsiella spp. VAP was associated (p < 0.05) with prior hospitalization (61.1 vs. 40.0%), diabetes mellitus (30.6 vs. 5.8%), obesity (30.6 vs. 4.7%), prior antibiotic therapy (77.8 vs. 52.0%), prior treatment with cephalosporins (66.7 vs. 36.0%), and SOFA cardiovascular ≥ 3 (44.4 vs. 10.0%) at VAP onset. Patients with polybacterial VAP were more likely (p < 0.05) to be comatose (22.2 vs. 52.0%) and had a higher SAPS II score (median [IQR] 45.0 [35.25-51.1] vs. 50.0 [40.5-60.75]) at VAP onset. Polybacterial MDR Klebsiella spp. VAP had distinct demographic and clinical characteristics compared to monobacterial, and was associated with poorer outcomes.

Effect of an educational intervention on compliance with care bundle items to prevent ventilator-associated pneumonia

OBJECTIVES

We aimed to evaluate the effectiveness of our ventilator-associated pneumonia prevention bundle implemented by education of the nursing staff, and to describe the tendency of knowledge retention.

RESEARCH METHODOLOGY

A prospective, before-and-after study was performed. The ventilator-associated pneumonia prevention bundle was implemented through a single educational intervention of the nursing staff. The risk of ventilator-associated pneumonia over time was estimated using a Cox proportional cause-specific hazard model. Compliance to preventive measures was assessed at three time-points: before education, at three months and 12 months after education.

SETTING

A 29-bed mixed medical-surgical intensive care unit.

MAIN OUTCOME MEASURES

Ventilator-associate pneumonia incidence densities, the risk of ventilator-associated pneumonia, and compliance to preventive measures in the pre-implementation and post-implementation periods.

RESULTS

We analyzed the data of 251 patients. The incidence density of pneumonia decreased from 29.3/1000 to 15.3/1000 ventilator-days after the implementation of the prevention program. Patients in the post-implementation period had significantly lower risk to develop pneumonia (hazard ratio 0.34, 95 % confidence interval 0.19-0.61, p = 0.001). At 3 months of implementation, a significant improvement was detected to all the individual bundle components. Complete compliance increased from 16.2 % to 62.2 % (p < 0.001). Compliance with bundle components decreased to baseline levels after 12 months of implementation apart from head-of-bed elevation.

CONCLUSION

This study supports existing evidence that educational interventions improve compliance. The gained knowledge was well translated into clinical practice reflected by the decreasing ventilator-associated pneumonia rate. It may be assumed that a refresher educational session within 12 months after implementation is needed.

Intermittent versus continuous control of tracheal cuff pressure in patients undergoing mechanical ventilation: A systematic review and meta-analysis

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.

Efficacy of Intermittent and Continuous Subglottic Secretion Drainage in Preventing the Risk of Ventilator-Associated Pneumonia: A Meta-Analysis of Randomized Control Trials

Ventilator-associated pneumonia (VAP) is hospital-acquired pneumonia that develops 48 h or longer following mechanical ventilation. However, cuff pressure fluctuates significantly due to patient or tube movement, which might result in microaspiration. Subglottic secretion drainage (SSD) has been suggested as a method for VAP prevention bundles. This systematic review and meta-analysis aims to investigate the efficacy and safety of subglottic SSD in preventing VAP. The secondary outcomes of this study are to investigate the intensive care unit (ICU) stay length and mortality rate regarding VAP. This study followed the Preferred Reporting Item for Systematic Review and Meta-Analysis guidelines. A thorough search of PubMed, Embase, and the Web of Science was conducted between June and August 2022. The study analysis used the Mantel-Haenszel method, and the quality of the included study was assessed using the Cochrane Risk of Bias 2. Eighteen randomized controlled trials with a total of 2537 intubated patients were included. It was found that SSD was associated with a lower risk of VAP (RR 1.44; 95% CI; 1.20-1.73; p < 0.0001). The subgroup analysis (utilizing intermittent and continuous methods) found no statistically significant difference between the two groups (p = 0.28). The secondary endpoints showed that there was no significant difference in mortality (RR 1.02; 95% CI; 0.87-1.20; p = 0.83), but there were substantial differences in ICU stays (mean difference, 3.42 days; 95% CI; 2.07-4.76; p < 0.00001) in favor of the SSD group. This was based on a very low certainty of evidence due to concerns linked to the risk of bias and inconsistency. The use of SSD was associated with a reduction in VAP incidence and ICU stay length, but there was no significant difference in the mortality rate.

Airway and Respiratory Devices in the Prevention of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is the most common ICU-acquired infection among patients under mechanical ventilation (MV). It may occur in up to 50% of mechanically ventilated patients and is associated with an increased duration of MV, antibiotic consumption, increased morbidity, and mortality. VAP prevention is a multifaceted priority of the intensive care team. The use of specialized artificial airways and other devices can have an impact on the prevention of VAP. However, these devices can also have adverse effects, and aspects of their efficacy in the prevention of VAP are still a matter of debate. This article provides a narrative review of how different airway and respiratory devices may help to reduce the incidence of VAP.

Mechanical ventilation in dogs and cats with tick paralysis

Respiratory failure from tick paralysis (TP) is an important cause of mortality in cats and dogs in Australia, occurring from a combination of respiratory muscle paralysis, upper respiratory tract obstruction and pulmonary disease. Patients may require positive-pressure ventilation in management of any combination of hypoxemia, hypoventilation or respiratory fatigue, but may also require airway management due to laryngeal paralysis. No single ventilation strategy is recommended due to the heterogenous disease presentations. Lung protective ventilation should be used in patients with pulmonary disease. Due to local and systemic effects of TP, patients are at higher risk of complications such as aspiration pneumonia and corneal ulceration and may have additional intravenous fluid and nutritional considerations. Treatment with hyperimmune serum is associated with improved outcomes. Prognosis is considered good with documented survival to discharge (STD) of 52.6-77% for animals with TP ventilated with lung disease and 90.5% for animals without lung disease. Median reported duration of ventilation for TP ranges from 23 to 48 h (range 3 h-10 days). The severity of individual neuromuscular signs and the presence of associated conditions such as aspiration pneumonia and laryngeal paralysis may necessitate longer periods of mechanical ventilation. This review aims to summarize the current recommendations regarding indications, management and prognosis of cats and dogs undergoing MV for TP and to identify areas for future research.

Use of an innovative cuff pressure control and subglottic secretions drainage system in COVID-19 ARDS patients undergoing pronation

We conducted a proof of concept study where Anapnoguard endotracheal tubes and its control unit were used in 15 patients with COVID-19 acute respiratory distress syndrome. Anapnoguard system provides suction, venting, rinsing of subglottic space and controls cuff pressure detecting air leakage through the cuff. Alpha-amylase and pepsin levels, as oropharyngeal and gastric microaspiration markers, were assessed from 85 tracheal aspirates in the first 72 h after connection to the system. Oropharyngeal microaspiration occurred in 47 cases (55%). Episodes of gastric microaspiration were not detected. Patient positioning, either prone or supine, did not affect alpha-amylase and pepsin concentration in tracheal secretions. Ventilator-associated pneumonia (VAP) rate was 40%. The use of the AG system provided effective cuff pressure control and subglottic secretions drainage. Despite this, no reduction in the incidence of VAP has been demonstrated, compared to data reported in the current COVID-19 literature. The value of this new technology is worth of being evaluated for the prevention of ventilator-associated respiratory tract infections.