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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.
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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.
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Abstract
This review documents important progress made in 2015 in the field of critical care. Significant advances in 2015 included further evidence for early implementation of low tidal volume ventilation as well as new insights into the role of open lung biopsy, diaphragmatic dysfunction, and a potential mechanism for ventilator-induced fibroproliferation. New therapies, including a novel low-flow extracorporeal CO2 removal technique and mesenchymal stem cell-derived microparticles, have also been studied. Several studies examining the role of improved diagnosis and prevention of ventilator-associated pneumonia also showed relevant results. This review examines articles published in the American Journal of Respiratory and Critical Care Medicine and other major journals that have made significant advances in the field of critical care in 2015.
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Affiliation(s)
- Martin Dres
- 1 Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care and
| | - Jordi Mancebo
- 3 Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Gerard F Curley
- 1 Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care and.,4 Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; and
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Klompas M, Berra L, Branson R. Beware the siren's song of novel endotracheal tube designs. Intensive Care Med 2017; 43:1708-1711. [PMID: 28364302 DOI: 10.1007/s00134-017-4778-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/15/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Richard Branson
- Division of Trauma and Critical Care, University of Cincinnati, 231 Albert Sabin Way #558, Cincinnati, OH, 545267, USA.
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Jaillette E, Girault C, Brunin G, Zerimech F, Behal H, Chiche A, Broucqsault-Dedrie C, Fayolle C, Minacori F, Alves I, Barrailler S, Labreuche J, Robriquet L, Tamion F, Delaporte E, Thellier D, Delcourte C, Duhamel A, Nseir S. Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: a multicenter cluster-randomized cross-over controlled trial. Intensive Care Med 2017; 43:1562-1571. [PMID: 28303301 DOI: 10.1007/s00134-017-4736-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/22/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE Studies on the impact of tapered-cuff tracheal tubes on rates of microaspiration and ventilator-associated pneumonia (VAP) in intubated patients have reported conflicting results. The aim of this study was to determine the influence of this shape of tracheal cuff on abundant microaspiration of gastric contents in critically ill patients. METHODS All patients intubated in the intensive care unit (ICU) and requiring mechanical ventilation for at least 48 h were eligible for this multicenter cluster-randomized controlled cross-over open-label study. The primary outcome was abundant microaspiration of gastric contents, defined by the presence of pepsin at significant level in >30% of tracheal aspirates. Quantitative measurement of pepsin and salivary amylase was performed in all tracheal aspirates during the 48 h following enrollment. RESULTS A total of 326 patients were enrolled in the ten participating ICUs (162 in the PVC tapered-cuff group and 164 in the standard-cuff group). Patient characteristics were similar in the two study groups. The proportion of patients with abundant microaspiration of gastric contents was 53.5% in the tapered-cuff and 51.0% in the standard-cuff group (odds ratio 1.14, 95% CI 0.72-1.82). While abundant microaspiration of oropharyngeal secretions was not significantly different (77.4 vs 68.6%, p = 0.095), the proportion of patients with tracheobronchial colonization was significantly lower (29.6 vs 43.3%, p = 0.01) in the tapered-cuff than in the standard-cuff group. No significant difference between the two groups was found for other secondary outcomes, including ventilator-associated events and VAP. CONCLUSIONS This trial showed no significant impact of tapered-cuff tracheal tubes on abundant microaspiration of gastric contents. TRIAL REGISTRATION ClinicalTrials.gov, number NCT01948635.
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Affiliation(s)
| | - Christophe Girault
- Department of Medical Intensive Care, Rouen University Hospital, and UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France
| | - Guillaume Brunin
- CH Dr Duchenne, Réanimation Polyvalente, Allée Jacques Monod, BP 609, 62321, Boulogne-Sur-Mer, France
| | - Farid Zerimech
- CHU de Lille, Pôle de Biologie Pathologie Génétique, Laboratoire de Biochimie et Biologie Moléculaire, 59000, Lille, France
| | - Hélène Behal
- CHU Lille, Clinique de Santé Publique, plateforme d'aide méthodologique, 59037, Lille Cedex, France
| | - Arnaud Chiche
- Réanimation Médicale et Infectieuse, 115 rue du Président Coty, 59208, Tourcoing Cedex, France
| | - Céline Broucqsault-Dedrie
- CH de Roubaix, Réanimation Polyvalente, Hôpital Victor Provo, 17 bd Lacordaire, BP 359, 59056, Roubaix, France
| | - Cyril Fayolle
- CH de Dunkerque, Service de réanimation polyvalente, 130 Avenue Louis Herbeaux BP 6367, 59140, Dunkerque, France
| | - Franck Minacori
- CH Saint Philibert, Réanimation Polyvalente, 115 Rue du Grand But, BP 249, 59462, Lomme Cedex, France
| | - Isabelle Alves
- Réanimation Médicale, CH de Valenciennes, Avenue Desandrouin, BP479, 59322, Valenciennes Cedex, France
| | - Stéphanie Barrailler
- CH Dr Schaffner, Réanimation Polyvalente, 99 route de La Bassée, BP8, 62307, Lens Cedex, France
| | - Julien Labreuche
- CHU Lille, Clinique de Santé Publique, plateforme d'aide méthodologique, 59037, Lille Cedex, France
| | - Laurent Robriquet
- CHU Lille, Critical Care Center, rue E. Laine, 59037, Lille cedex, France
| | - Fabienne Tamion
- Department of Medical Intensive Care, Rouen University Hospital, and UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France
| | - Emmanuel Delaporte
- CH Dr Duchenne, Réanimation Polyvalente, Allée Jacques Monod, BP 609, 62321, Boulogne-Sur-Mer, France
| | - Damien Thellier
- Réanimation Médicale et Infectieuse, 115 rue du Président Coty, 59208, Tourcoing Cedex, France
| | - Claire Delcourte
- CHU Lille, Critical Care Center, rue E. Laine, 59037, Lille cedex, France
| | - Alain Duhamel
- CHU Lille, Clinique de Santé Publique, plateforme d'aide méthodologique, 59037, Lille Cedex, France
| | - Saad Nseir
- CHU Lille, Critical Care Center, rue E. Laine, 59037, Lille cedex, France.
- Lille University, Medical School, 59000, Lille, France.
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Mariyaselvam MZ, Marsh LL, Bamford S, Smith A, Wise MP, Williams DW. Endotracheal tubes and fluid aspiration: an in vitro evaluation of new cuff technologies. BMC Anesthesiol 2017; 17:36. [PMID: 28257624 PMCID: PMC5336650 DOI: 10.1186/s12871-017-0328-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/20/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aspiration of subglottic secretions past the endotracheal tube (ETT) cuff is a prerequisite for developing ventilator-associated pneumonia (VAP). Subglottic secretion drainage (SSD) ETTs reduce aspiration of subglottic secretions and have demonstrated lower VAP rates. We compared the performance of seven SSD ETTs against a non-SSD ETT in preventing aspiration below inflated cuffs. METHODS ETTs were positioned vertically in 2 cm diameter cylinders. Four ml of a standard microbial suspension was added above inflated cuffs. After 1 h, aspiration was measured and ETTs demonstrating no leakage were subjected to rotational movement and evaluation over 24 h. Collected aspirated fluid was used to inoculate agar media and incubated aerobically at 37 °C for 24 h. The aspiration rate, volume and number of microorganisms that leaked past the cuff was measured. Experiments were repeated (×10) for each type of ETT, with new ETTs used for each repeat. Best performing ETTs were then tested in five different cylinder diameters (1.6, 1.8, 2.0, 2.2 and 2.4 cm). Experiments were repeated as above using sterile water. Volume and time taken for aspiration past the cuff was measured. Experiments were repeated (×10) for each type of ETT. Results were analysed using non-parametric tests for repeated measures. RESULTS The PneuX ETT prevented aspiration past the cuff in all experiments. All other ETTs allowed aspiration, with considerable variability in performance. The PneuX ETT was statistically superior in reducing aspiration compared to the SealGuard (p < 0.009), KimVent (p < 0.002), TaperGuard (p < 0.004), Lanz (p < 0.001), ISIS (p < 0.001), SACETT (p < 0.001) and Soft Seal (p < 0.001) ETTs. Of the 4 ETTs tested in differing cylinder sizes, the PneuX significantly reduced aspiration across the range of diameters compared to the SealGuard (p < 0.0001), TaperGuard (p < 0.0001) and KimVent (p < 0.0001) ETTs. CONCLUSIONS ETTs showed substantial variation in fluid aspiration, relating to cuff material and design. Variability in performance was likely due to the random manner in which involutional folds form in the inflated ETT cuff. The PneuX ETT was the only ETT able to consistently prevent aspiration past the cuff in all experiments.
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Affiliation(s)
- Maryanne Z Mariyaselvam
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK.
| | - Lucy L Marsh
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK
| | - Sarah Bamford
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK
| | - Ann Smith
- School of Biosciences, Cardiff University, Cardiff, Wales, UK
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, Wales, UK
| | - David W Williams
- Oral and Biomedical Sciences, School of Dentistry, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XY, UK
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