Subglottic Secretion Research Articles

Research progress of flushing of the subglottic secretion in preventing VAP

Ventilator-associated pneumonia (VAP) has become one of the most common and severe complications in patients with mechanical ventilation due to its high morbidity and mortality rates, and is an important cause of death in critically ill patients. Pathogenic oropharyngeal colonization mostly accumulates in the subglottic secretion, which is easy to be ignored and difficult to be cleaned. The leakage of subglottic secretion can result in pathogenic oropharyngeal colonization in the lung, and in turn cause VAP. Flushing of the subglottic secretion can effectively prevent VAP. Selection and amount of rinses, flushing frequency and proper cuff pressure maintenance during flushing were reviewed in the current study. Key words: Review; Ventilator-associated pneumonia; Flushing of the subglottic; Colonized bacteria

Prevention of ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is an iatrogenic disease. Here we appraise recent advancements in the development and testing of strategies to prevent VAP. We also provide recommendations on the most promising interventions that should be applied. In the last year, preventive bundles have consistently let to a reduction of VAP. A few trials on endotracheal tubes (ETTs) with novel cuffs failed to translate positive bench findings into clinical settings. In addition, meta-analyses confirmed the primary role of subglottic secretion aspiration in VAP prevention. A relatively new ETT, with an innovative cuff design, has been tested in clinical trials confirming potential value. Meta-analyses confirmed reduction of VAP with the use of chlorhexidine for oropharyngeal decontamination. However, prophylactic inhaled or oral antibiotics are ineffective. Finally, there is growing interest in orally ingested probiotics to prevent VAP. The results of ongoing studies on probiotics are much-awaited. In conclusion, in the past year, new evidence elucidated limitations of new ETT cuffs in the prevention of VAP; whereas, subglottic secretion aspiration proved consistent benefits. Modulation of oropharyngeal colonization with chlorhexidine decreases risks of VAP and should be widely implemented. Finally, preventive measures with proven preventive value should be grouped into bundles.

Endotracheal tubes and fluid aspiration: an in vitro evaluation of new cuff technologies

BackgroundAspiration 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.MethodsETTs 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.ResultsThe 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.ConclusionsETTs 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.

Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization

The effectiveness of prevention bundles on the occurrence and mortality of ventilator associated pneumonia (VAP) was evaluated in many studies. However, the effectiveness of endotracheal tube with subglottic secretion drainage (ETT-SD) and cuff pressure monitorization in VAP bundles have not been adequately assessed. In this study, we aimed to evaluate the effectiveness of VAP bundle containing ETT-SD and cuff pressure monitorization. This was a prospective, controlled study that was carried out between March 2011 and April 2012 including intubated patients. The study was conducted at the Anesthesiology Intensive Care Unit 1 and 2 (10 beds each) in a 898-bed university hospital. Occurrence of VAP and compliance with the parameters of the VAP prevention bundles were assessed daily. Patients intubated with the standard endotracheal tube were recruited as controls, mainly in the first six months of the study as ETT-SD and cuff pressure monometer had not yet been implemented. In the second term, patients intubated with ETT-SD were included as cases. Occurrence of VAP, mortality, and compliance with VAP prevention bundles were monitored. A total of 133 patients, 37 cases and 96 controls were recruited. VAP incidence declined from 40.82 to 22.16 per 1000 ventilator days among controls and cases, respectively (p<005). On average, VAP occurred 17.33±21.09 days in the case group and 10.43±7.83 days in the control group (p=0.04). However, mortality of cases and controls at the 14th and 30th days was not different. VAP prevention bundles including the utilization of ETT-SD, monitoring cuff pressure, and oral care with chlorhexidine were efficient in reducing the rate of VAP.

気管チューブカフ上部吸引の有効性に関連する因子の検討

近年，人工呼吸器関連肺炎（VAP）の予防策の一つとして，気管チューブに付属した専用のポートから吸引する，カフ上部吸引（subglottic secretion drainage：SSD）の有効性が示されている．本研究では，気管挿管，気管切開を行った患者56名を対象とし，カフ上部から吸引される分泌物の有無の関連因子を検討した．結果，気管切開チューブを使用している患者の方が，気管内チューブを使用している患者に比べ，約5倍カフ上部から分泌物が吸引されやすい傾向にあることが明らかとなった．その要因として，「チューブ挿入部周囲の組織の構造および位置」，「気管チューブの構造」の2点が推察された．今後は，カフ上部吸引回数やカフ上部吸引のタイミング，吸引量などの因子を加えて検討を行い，サイレントアスピレーションの予防に努める必要がある．

The effect of oral care on the prevention of ventilator associated pneumonia in patients with severe traumatic brain injury by aspiration of subglottic secretion combined with 2% acetic acid chloride solution

Objective To explore the effect of oral care on the prevention of ventilator associated pneumonia in patients with severe traumatic brain injury by aspiration of subglottic secretion combined with 2% acetic acid chloride solution. Methods A total of 100 cases of ICU patients with mechanical ventilation for longer than 48 hours were divided into group B and group C using a random number table method according to tracheotomy mechanical ventilation time sequence number from January 2014 to June 2015. Another 50 ICU patients in group A (as the case for retrospective analysis, from April to November, 2013) were treated by routine tracheal suction, normal saline cotton for oral care, group B were treated with aspiration of subglottic secretion, normal saline cotton for oral care, group C were treated with aspiration of subglottic secretion combined with 2% acetic acid chloride solution for oral cleaning. And then VAP occurrence rate, plaque index, plaque clearance were evaluated. Results The incidence rates of early onset VAP in three groups were 14% (7/50), 8% (4/50), 4% (2/50), and incidence rates of late onset VAP were 22% (11/50),12% (6/50), 8% (4/50) respectively, the differences were significant (χ2=3.65, 3.88, P <0.01). The plaque index and plaque clearance rates of the three groups on the third day were 2.14± 0.35, (40.12±13.11)%, 2.10±0.33, (39.17± 14.21)%, 1.03±0.24, (60.12±15.07 )%(F =12.21, χ2 =3.82, P < 0.01); while on the 7th day, they were 1.76±0.47, (41.12±13.34)%, 1.80±0.32, (39.37±12.21)%, 0.99±0.15, (60.33±14.25)% (F=13.14, χ2=4.20, P <0.01). Conclusions The incidence rate of VAP can be decreased by the combination of aspiration of subglottic secretion and oral cleaning with 2% acetic acid chloride solution. Key words: Pneumonia, ventilator-associated; Aspiration of subglottic secretion; Oral care; Severe craniocerebral injury; 2% acetic acid chloride solution

A prospective randomized trial of tapered-cuff endotracheal tubes with intermittent subglottic suctioning in preventing ventilator-associated pneumonia in critically ill patients

BackgroundEndotracheal tube placement is necessary for the control of the airway in patients who are mechanically ventilated. However, prolonged duration of endotracheal tube placement contributes to the development of ventilator-associated pneumonias (VAPs). The aim of this study was to evaluate whether subglottic suctioning using TaperGuard EVAC tubes was effective in decreasing the frequency of VAP. MethodsA total of 276 mechanically ventilated patients for more than 72 hours were randomly assigned to group E (EVAC tube) and group C (conventional tube). All patients received routine care including VAP prevention measures during their intensive care unit stay. In group E, subglottic suctioning was performed every 6 hours. Outcome variables included incidence VAP, intensive care unit length of stay, and mortality. ResultsFrequency of intraluminal suction, mechanical ventilation–free days, reintubation, the ratio of arterial oxygen partial pressure to fractional inspired oxygen and mortality rate were similar between the 2 groups (P > .05). The mean cuff pressure in group E was significantly less than that in group C (P < .001). Ventilator-associated pneumonia was significantly less in group E compared with group C (P = .015). ConclusionThe use of intermittent subglottic secretion suctioning was associated with a significant decrease in the incidence of the VAP in critically ill patients. However, larger multicenter trials are required to arrive at a concrete decision on routine usage of TaperGuard tubes in critical care settings.

Subglottic secretion suction for preventing ventilator-associated pneumonia: an updated meta-analysis and trial sequential analysis.

BackgroundPotential benefits of subglottic secretion suction for preventing ventilator-associated pneumonia (VAP) are not fully understood.MethodsWe searched Cochrane Central, PubMed, and EMBASE up to March 2016 to identify randomized controlled trials (RCTs) that compared subglottic secretion suction versus non-subglottic secretion suction in adults with mechanical ventilation. Meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. The primary outcome was incidence of VAP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the level of evidence.ResultsTwenty RCTs (N = 3544) were identified. Subglottic secretion suction was associated with reduction of VAP incidence in four high quality trials (relative risk (RR) 0.54, 95 % confidence interval (CI) 0.40–0.74; p < 0.00001) and in all trials (RR = 0.55, 95 % CI 0.48– 0.63; p < 0.00001). Sensitivity analyses did not show differences in the pooled results. Additionally, the results of the above-mentioned analyses were confirmed in TSA. GRADE level was high. Subglottic secretion suction significantly reduced incidence of early onset VAP, gram-positive or gram-negative bacteria causing VAP, and duration of mechanical ventilation. It delayed the time-to-onset of VAP. However, no significant differences in late onset VAP, intensive care unit (ICU) mortality, hospital mortality, or ICU length of stay were found.ConclusionsSubglottic secretion suction decreased VAP incidence and duration of mechanical ventilation and delayed VAP onset. However, subglottic secretion suction did not reduce mortality and length of ICU stay. Subglottic secretion suction is recommended for preventing VAP and for reducing ventilation length, especially in the population at high risk of early onset VAP.Trial registrationA protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42015015715); registered on 5 January 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1527-7) contains supplementary material, which is available to authorized users.

Determining Aspiration of Oral Secretions and the Potential Impact on Evaluation of Dysphagia and VAP in Patients With Tracheostomies Using an Automated Intermittent Subglottic Aspiration System

SESSION TITLE: Respiratory Care SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: The Modified Evans Blue Dye Test (MEBDT) has been formally used since 1995 to evaluate aspiration in patients with tracheostomies who frequently have dysphagia or other swallowing problems. In the test, clinicians deflate the cuff of the tracheal tube. Blue dye (typically FD&C Blue No. 1) is added to food (e.g. applesauce) and then fed to the patient. Following suctioning of the lower regions of the tracheal tube, past the deflated cuff, if any dye is seen in the suctioned fluids, the patient is diagnosed with a swallowing disorder, since the contaminated contents were drawn from the lower airways, where they can cause ventilator-associated pneumonia (VAP) and ventilator-associated events (VAE). The reliability, sensitivity, and specificity of the MEBDT have long been questioned. The test relies on important factors such as duration of suctioning and operator technique. False negative results have been shown to occur in over 50% of tests performed, putting patients at risk. METHODS: The automated intermittent subglottic aspiration system is FDA cleared and specifically approved for the removal of subglottic secretion drainage from above the ballooned cuff of tracheal tubes with an integrated suction port. The system facilitates the intermittent suctioning of oropharynx and gastric secretions before they can travel beyond the cuff and into the lungs. In this separate and novel application, the clinician places a few drops of green dye on the back of the tongue of the patient, then suctions secretions from above the ballooned cuff using the aspiration system. If green dye is collected in the disposal canister of the system, the presence of aspirated oral secretions is identified. RESULTS: The new technique offers multiple potential improvements over the traditional MEBDT. The new method does not require that a patient ingest foods, and does not require that dye travel beyond a deflated cuff to be collected in the lower airways by tracheal suction. In a trial study of 10 patients who were tracheostomized on mechanical ventilation and passed the MEBDT, aspiration of oral secretions was identified with this new assessment. These findings can predict the increased risk of saliva and oral secretion aspiration and potential VAE. In addition, it raises the question of clinical significance of the relationship between aspiration of oral secretions and potential aspiration of food. CONCLUSIONS: The new technique which uses small amounts of green dye on the tongue in combination with the automated intermittent aspiration system offers a potentially safe, highly accurate, and well tolerated way to diagnose aspiration of oral secretions and the increased risk of potential aspiration of food. CLINICAL IMPLICATIONS: This new test eliminates the variables that make the Evan's Modified Blue Dye test unreliable and ineffective at the diagnosis of dysphagia. This new test also eliminates the need for the patient to actually aspirate the apple sauce and dye in order to make a positive diagnosis of dysphagia. The new technique also can record the actual volume of secretion microaspiration that can lead to VAE in mechanically ventilated patients. This test is non-invasive and tolerated well by the patients. DISCLOSURE: The following authors have nothing to disclose: Gerald Gentile No Product/Research Disclosure Information

Investigation of current situation of nursing management on drainage of subglottic secretion

Objective To explore the current situation of nursing management on drainage of subglottic secretion in ICU in order to provide references for nursing managers to develop relevant measures and standard clinical technique of subglottic secretion drainage. Methods The questionnaire professional network research platform, the convenient sampling method and self-designed questionnaire were used to investigate 293 ICU nurses from 20 provinces and cities. Results The departments, which had routine drainage of subglottic secretion, accounted for 81.02%, and the one formulated operational standards and procedures accounted for 77.97%. The departments that had used special subglottic drainage equipment only 26.44%. The departments that had knowledge trained on drainage of subglottic secretion accounted for 53.90%, while the departments with different nursing bed ratio had statistical differences in the SSD related knowledge training(χ2=8.059, P<0.05), the needs for knowledge of nursing staff on the drainage of subglottic secretion accounted for 89.83%, which 80.00% of them hope the way to obtain knowledgehope was department training. Conclusions In order to improve the effect of subglottic secretions drainage, clinical nursing managers need to improve the standard management of the drainage of subglottic secretion, perfect the equipment of drainage, strengthen the nursing human resources allocation and department training. Key words: Nurse; Management; Drainage technology; Subglottic secretion; ICU

The value of polyurethane-cuffed endotracheal tubes to reduce microaspiration and intubation-related pneumonia: a systematic review of laboratory and clinical studies.

BackgroundWhen 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.MethodsWe 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.ResultsThe 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.ConclusionsCurrent 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 materialThe online version of this article (doi:10.1186/s13054-016-1380-8) contains supplementary material, which is available to authorized users.

Subglottic Secretion Drainage and Objective Outcomes

Current guidelines recommend endotracheal tubes with subglottic secretion drainage to prevent ventilator-associated pneumonia. Subglottic secretion drainage is associated with fewer ventilator-associated pneumonia diagnoses, but it is unclear to what extent this reflects fewer invasive pneumonias versus fewer false-positive diagnoses due to less secretions and/or less microbial colonization of the oropharynx. We, therefore, undertook a systematic review and meta-analysis of the impact of subglottic secretion drainage on duration of mechanical ventilation, ICU and hospital length of stay, ventilator-associated events, mortality, antibiotic utilization, stridor, and reintubations to better understand the net benefits and limitations of this intervention. We searched Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, and PubMed from inception through February 22, 2015, without language restrictions. Randomized controlled trials comparing subglottic secretion drainage versus no subglottic secretion drainage in adult patients on mechanical ventilation. Eligible trials were abstracted and assessed for risk of bias by two reviewers. We identified 17 eligible trials with a total of 3,369 patients. Subglottic secretion drainage was associated with lower ventilator-associated pneumonia rates (risk ratio, 0.58; 95% CI, 0.51-0.67; I2 = 0%), but there were no significant differences between groups in duration of mechanical ventilation (weighted mean difference, -0.16 d; 95% CI, -0.64 to 0.33; I2 = 0%), ICU length of stay (weighted mean difference, +0.17 d; 95% CI, -0.62 to 0.95; I2 = 0%), hospital length of stay (weighted mean difference, -0.57 d; 95% CI, -2.44 to 1.30; I2 = 0%), ventilator-associated events (risk ratio, 0.97; 95% CI, 0.65-1.43), or mortality (risk ratio, 0.93; 95% CI, 0.84-1.03; I2 = 0%). Two studies observed significantly less antibiotic use with subglottic secretion drainage whereas a third did not. There were no significant differences between groups in stridor or reintubations. Subglottic secretion drainage is associated with lower ventilator-associated pneumonia rates but does not clearly decrease duration of mechanical ventilation, length of stay, ventilator-associated events, mortality, or antibiotic usage. Further data are required to demonstrate the benefits of subglottic secretion drainage.

Multivariate analysis and countermeasures of attracted subglottic secretion volume

Objective To explore the factors related to the amount of suction under glottis, look for effective nursing counter measures in order to improve the suction effects. Methods A retrospective analysis of the clinical data of 71 patients with subglottic secretion drainage from 1st January 2013 to 1st May 2014 was performed. The secretion viscosity, posture, the endotracheal tube cuff pressure, patients restlessness, suction pressure, and acute physiology and chronic health evaluationⅡscore were set as independent variables. A multiple linear regression analysis was performed to screen factors that may lead to reduction of suction volume of subglottic secretion and nursing counter measures were planned and implemented accordingly. Results Secretion viscosity, supine, endotracheal tube cuff pressure and patient restlessness were the main reasons that influence the amount of suction under glottis(P<0.05). Multiple linear regression equation: amount of suction of subglottic secretion/2 h(ml)=4.868+ 2.470×restlessness-1.624×secretion viscosity+ 0.874×endotracheal tube cuff pressure-0.933×posture. Conclusions Quantity of suction of subglottic secretion were positively correlated to patients′ restlessness, secretion viscosity and endotracheal tube cuff pressure. Subglottic attract amount for the most when take left lateral position. Strengthening the control and intervention of related factors plays a very important role in the care of suction under glottis. Key words: Subglottic; Suction; Related factors; Multiple linear regression analysis

New Strategies to Prevent Ventilator-Associated Pneumonia: What to Do for Your Patients

The current rates of ventilator-associated pneumonia (VAP) are falling, in large part, as a result of effective prevention strategies. However, the application and efficacy of VAP prevention is being challenged by efforts to replace VAP surveillance with monitoring for ventilator-associated complications (VAC), which include many non-infectious processes. VAP prevention is based on interrupting pneumonia pathogenesis by avoiding the inoculation of contaminated oral secretions into the lower respiratory tract. This starts by using non-invasive ventilation in place of endotracheal intubation whenever possible, placing all tracheal and gastric tubes through the mouth and not the nose, and making daily efforts to liberate patients from mechanical ventilation. Intervention strategies to avoid microaspiration of oral contents to the lung have focused on the use of modified respiratory therapy equipment. This includes endotracheal tubes with subglottic secretion drainage channels, endotracheal tube cuffs made of special materials and of special shape, adaptation of endotracheal tube materials to prevent the development of biofilm, cleaning tubes with biofilm removal devices, and using devices to maintain endotracheal tube cuff pressure. Decontamination of oral secretions with chlorhexidine is commonly incorporated, as part of routine oral care, in many patients. The use of 24 h of prophylactic antibiotics after emergent intubation is also a valuable strategy, but controversy about selective digestive and selective oral decontamination persists, because of concerns about the emergence of antibiotic resistance, particularly in ICUs with high baseline rates of resistance. Other interventions are of less certain benefit, such as post-pyloric feeding, elevation of the head of the bed, and use of probiotics. This review makes recommendations about which current prevention strategies have the greatest potential to reduce the frequency of VAP.

Use of endotracheal tubes with subglottic secretion drainage reduces ventilator-associated pneumonia in trauma patients.

Patients sustaining traumatic injuries have a higher incidence of ventilator-associated pneumonia (VAP) compared with other critically ill patient populations. Previous studies of patients with predominantly medical diagnoses and use of endotracheal tubes allowing subglottic secretion drainage (ETT-SSD) have shown significant reduction in VAP rates. We hypothesized that the use of ETT-SSD would reduce VAP in trauma patients. A retrospective review from 2010 to 2014 of adult trauma patients orotracheally intubated for more than 48 hours was performed at a Level 1 trauma center. Patients were compared based on standard endotracheal tube (ETT) versus ETT-SSD for the primary outcome VAP per 1,000 ventilator days. The diagnosis of VAP was made by quantitative bronchoalveolar lavage cultures as defined by Centers for Disease Control and Prevention criteria. Patients with ETT-SSD were matched to patients with ETT based on age group, sex, mechanism of injury, head and chest Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS). Of 1,135 patients included in the study, 667 patients had ETT and 468 had ETT-SSD. Groups did not differ by demographics, mechanism of injury, Glasgow Coma Scale (GCS) score, alcohol intoxication, or ISS. Patients with ETT-SSD had significantly higher head AIS score but lower chest AIS score. In matched cohorts, ETT-SSD had a lower VAP rate (5.7 vs. 9.3 for ETT, p = 0.03), decreased ventilator days (12 vs. 14, p = 0.04), and decreased intensive care unit length of stay (13 days vs. 16 days, p = 0.003). After controlling for confounding factors, ETT-SSD decreased VAP rate, ventilator days, and intensive care unit length of stay in trauma patients. In this high-risk patient population, we recommend routine use of ETT-SSD to decrease VAP. Therapeutic/care management study, level III.

Predicting Which Patients will Likely Benefit from Subglottic Secretion Drainage Endotracheal Tubes: A Retrospective Study

BackgroundSubglottic secretion drainage endotracheal tubes (SSD ETTs) have been shown to decrease ventilator-associated pneumonia and are recommended for patients intubated > 48 h or 72 h. However, it is difficult to determine which patients will be intubated > 48 h or 72 h at the time of intubation. ObjectiveWe attempted to determine which patient characteristics were associated with intubations ≥ 48 h or 72 h in order to guide proper placement of SSD ETTs. MethodsThe medical records of 2,159 ventilated patients at a single institution were retrospectively reviewed for intubation duration, age, sex, race, body mass index, weight, intubation reason, whether the intubation was emergent, operative status, intensive care unit (ICU) diagnosis, intubation location, ICU location, comorbidities (e.g., congestive heart failure, chronic obstructive pulmonary disorder, coronary artery disease, dementia, and liver disease), acute kidney injury (AKI), and chronic renal injury. A multivariate regression analysis was then performed with all reliable data. ResultsThe following were associated with intubation ≥ 48 h: neuroscience critical care unit (NCCU) admission (risk ratio [RR] = 1.85; 95% confidence interval [CI] 1.34–2.56), emergent intubation (RR = 1.97; 95% 1.28–3.03), comorbid dementia (RR = 2.31; 95% 1.28–4.18), nonoperative intubation (RR = 1.77; 95% 1.28–4.18), and AKI (RR = 3.32; 95% 2.56–4.3). The following were independently associated with intubation ≥ 72 h: NCCU admission (RR = 2.2; 95 CI 1.57–3.08), nonoperative intubation (RR = 3.38; 95% CI 2.63–4.35), comorbid dementia (RR = 3.03; 95% CI 1.67–5.48), and AKI (RR = 3.11; 95% CI 2.38–4.07). ConclusionNonoperative intubation, emergent intubation, history of dementia, admission to NCCU and AKI all appear to be independently associated with increased RRs for either ≥ 48 h or 72 h of ventilation.

Efficacy of Hi-Lo Evac Endotracheal Tube in Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Poisoned Patients.

Background. Ventilator-associated pneumonia (VAP) is the most common health care-associated infection. To prevent this complication, aspiration of subglottic secretions using Hi-Lo Evac endotracheal tube (Evac ETT) is a recommended intervention. However, there are some reports on Evac ETT dysfunction. We aimed to compare the incidence of VAP (per ventilated patients) in severely ill poisoned patients who were intubated using Evac ETT versus conventional endotracheal tubes (C-ETT) in our toxicology ICU. Materials and Methods. In this clinical randomized trial, 91 eligible patients with an expected duration of mechanical ventilation of more than 48 hours were recruited and randomly assigned into two groups: (1) subglottic secretion drainage (SSD) group who were intubated by Evac ETT (n = 43) and (2) control group who were intubated by C-ETT (n = 48). Results. Of the 91 eligible patients, 56 (61.5%) were male. VAP was detected in 24 of 43 (55.8%) patients in the case group and 23 of 48 (47.9%) patients in the control group (P = 0.45). The most frequently isolated microorganisms were S. aureus (54.10%) and Acinetobacter spp. (19.68%). The incidence of VAP and ICU length of stay were not significantly different between the two groups, but duration of intubation was statistically different and was longer in the SSD group. Mortality rate was less in SSD group but without a significant difference (P = 0.68). Conclusion. The SSD procedure was performed intermittently with one-hour intervals using 10 mL syringe. Subglottic secretion drainage does not significantly reduce the incidence of VAP in patients receiving MV. This strategy appears to be ineffective in preventing VAP among ICU patients.

Randomized Pilot Trial of Two Modified Endotracheal Tubes To Prevent Ventilator-associated Pneumonia

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. 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. 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. 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. 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).

Comparison of suction above cuff and standard endotracheal tubes in neurological patients for the incidence of ventilator-associated pneumonia and in-hospital outcome: A randomized controlled pilot study.

Background:Ventilator-associated pneumonia (VAP) is a common complication with endotracheal intubation. The occurrence of VAP results in significant mortality and morbidity. Earlier studies have shown reduction in the incidence of VAP with subglottic secretion drainage. The incidence of VAP in neurologically injured patients is higher and can impact the neurological outcome. This study aimed to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurologically ill patients and its impact on clinical outcome.Methods:Fifty-four patients with neurological illnesses aged ≥18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT. All the VAP preventive measures were similar between two groups except for the difference in type of tube.Results:The data of 50 patients were analyzed. The incidence of clinical VAP was 20% in SETT group and 12% in SACETT group; (P = 0.70). The incidence of microbiological VAP was higher in the SETT group (52%) as compared to SACETT group (44%) but not statistically significant; (P = 0.78). There was no difference between the two groups for measured outcomes such as duration of intubation, mechanical ventilation, and Intensive Care Unit stay.Conclusions:In this pilot study in neurological population, a there was no significant difference in incidence of clinical and microbiological VAP was seen between SETT and SACETT, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation.

Efficacy of intermittent sub-glottic suctioning in prevention of ventilator-associated pneumonia- A preliminary study of 100 patients.

Background and Aims:Oropharyngeal colonisation followed by aspiration of contaminated secretions is the major cause for ventilator-associated pneumonia (VAP). Pooled secretions present in the sub-glottic area above inflated endotracheal tube cuff may be aspirated into the lower airways. It was hypothesised that intermittent suctioning of sub-glottic secretions would prevent VAP.Methods:Group I (n = 50) patients were intubated with HiLo Evac™ endotracheal (ET) tube with facility for sub-glottic suctioning, and Group II (n = 50) patients were intubated with HiLo Contour™ ET tube without such facility. In the Group I, sub-glottic suctioning was performed every 2 h. Incidence of VAP, mean ventilator days, Intensive Care Unit (ICU) stay and mortality were compared. Qualitative variables were reported as percentages and were compared by Chi-square test or unpaired two-tailed, Fisher's exact test, as appropriate, to analyse the significance of difference between the two groups.Results:The two groups were similar with respect to demographic characteristics. VAP was seen in 6% of patients in Group I and 22% of patients in Group II (P = 0.021). Both early- and late-onset VAPs were significantly reduced in Group I. Both ventilator days (8.0 vs. 6.45; P = 0.001) and ICU stay (8.33 vs. 6.33; P = 0.001) on the day of onset of VAP were significantly more in the Group I. Total ventilator days were significantly less (6.52 vs. 8.32; P = 0.006) with lower incidence of mortality (36% vs. 48%; P = 0.224) in the Group I.Conclusion:Intermittent sub-glottic suctioning reduces the incidence of VAP including late-onset VAP.