Rapid-flow expulsion maneuver in subglottic secretion clearance to prevent ventilator-associated pneumonia: a randomized controlled study

Ying Li,Hai-Chao Li,Li Wang,Xue Yuan,Bing Sun,Xiao Tang,Xu-Yan Li,Zhao-Hui Tong,Chen Wang,Hui-Wen Chu,Yu Zhao,Rui Wang

doi:10.1186/s13613-021-00887-5

Abstract

BackgroundFollowing endotracheal intubation, clearing secretions above the endotracheal tube cuff decreases the incidence of ventilator-associated pneumonia (VAP); therefore, subglottic secretion drainage (SSD) is widely advocated. Our group developed a novel technique to remove the subglottic secretions, the rapid-flow expulsion maneuver (RFEM). The objective of this study was to explore the effectiveness and safety of RFEM compared with SSD.MethodsThis study was a single-center, prospective, randomized and controlled trial, conducted at Respiratory Intensive Care Unit (ICU) of Beijing Chao-Yang Hospital, a university-affiliated tertiary hospital. The primary outcome was the incidence of VAP, assessed for non-inferiority.ResultsPatients with an endotracheal tube allowing drainage of subglottic secretions (n = 241) were randomly assigned to either the RFEM group (n = 120) or SSD group (n = 121). Eleven patients (9.17%) in the RFEM group and 13 (10.74%) in the SSD group developed VAP (difference, − 1.59; 95% confidence interval [CI] [− 9.20 6.03]), as the upper limit of 95% CI was not greater than the pre-defined non-inferiority limit (10%), RFEM was declared non-inferior to SSD. There were no statistically significant differences in the duration of mechanical ventilation, ICU mortality, or ICU length of stay and costs between groups. In terms of safety, no accidental extubation or maneuver-related barotrauma occurred in the RFEM group. The incidence of post-extubation laryngeal edema and reintubation was similar in both groups.ConclusionsRFEM is effective and safe, with non-inferiority compared to SSD in terms of the incidence of VAP. RFEM could be an alternative method in first-line treatment of respiratory ICU patients.Trial registration This study has been registered on ClinicalTrials.gov (Registration Number: NCT02032849, https://clinicaltrials.gov/ct2/show/NCT02032849); registered on January 2014

Highlights

Following endotracheal intubation, clearing secretions above the endotracheal tube cuff decreases the incidence of ventilator-associated pneumonia (VAP); subglottic secretion drainage (SSD) is widely advo‐ cated
Establishment of an artificial airway is an important treatment approach in critically ill patients, which is commonly complicated by ventilator-associated pneumonia (VAP)
Several studies have confirmed the effectiveness of subglottic secretion drainage (SSD) in reducing the incidence of VAP [4, 5]

Summary

Introduction

Following endotracheal intubation, clearing secretions above the endotracheal tube cuff decreases the incidence of ventilator-associated pneumonia (VAP); subglottic secretion drainage (SSD) is widely advo‐ cated. Establishment of an artificial airway is an important treatment approach in critically ill patients, which is commonly complicated by ventilator-associated pneumonia (VAP). The main cause of VAP is the accumulation of secretions in the gap between the glottis and the cuff after intubation, which cannot be cleared by coughing. This leads to the spread of pathogens in the lower respiratory tract [3]. Several studies have confirmed the effectiveness of subglottic secretion drainage (SSD) in reducing the incidence of VAP [4, 5]. Expensive specialized tubes are required, and the procedure is often accompanied by complications, such as airway mucosal injury, and poor drainage [9, 10]

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