Continuous Control of Tracheal Cuff Pressure and Microaspiration of Gastric Contents in Critically Ill Patients

Nseir, Saad; Zerimech, Farid; Fournier, C.; Lubret, Rémy; Ramon, P; Durocher, A.; Balduyck, Malika

doi:10.1164/rccm.201104-0630oc

Cited by 206 publications

(218 citation statements)

References 45 publications

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“…94 Continuous monitoring and control of tracheal cuff pressures have been shown to maintain adequate ETT cuff pressure and reduce the incidence of both microaspiration and VAP. 95,96 In these studies, automatic control of ETT cuff pressure maintained between 20 and 30 cm H 2 O in 98 -100% of observations reduced the incidence of VAP by 51-62%. Among controls, the percentage of subjects with incidences of ETT cuff pressure of Ͻ 20 cm H 2 O ranged from 9 to 55%.…”

Section: Modifiable Risk Factors For Ventilator-associated Pneumonia mentioning

confidence: 90%

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The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

Kallet

2015

Respir Care

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SummaryVentilator-associated pneumonia (VAP) is an acquired infection related primarily to the consequences of prolonged endotracheal intubation. It is considered the most important infectious challenge in the critical care setting. Preventable complications of hospital care are considered an important source of wasted health-care costs believed to consume up to 47% of annual expenditures in the United States. Whether VAP is preventable has become a highly contentious debate since public reporting commenced a decade ago. This selective review focuses on specific aspects of this debate, including the inherent vagaries in the diagnosis of VAP and the marked disparities between VAP rates based on clinical diagnosis versus surveillance data. Also discussed is how this debate has impacted public policy, leading to the new paradigm of ventilator-associated events. The limited ability of artificial airways to prevent microaspiration and biofilm build-up, as well as non-modifiable conditions increasing the risk of VAP, is described in detail. In addition, the origins of the mistaken but widely embraced notion that zero VAP is a realistic achievement are examined.

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Section: Modifiable Risk Factors For Ventilator-associated Pneumonia mentioning

confidence: 90%

“…Although maintaining adequate ETT cuff pressure is important in reducing microaspiration, it cannot eliminate the risk, as other unavoidable factors such endotracheal suctioning and patient movement contribute to the problem. 95 …”

Section: Modifiable Risk Factors For Ventilator-associated Pneumonia mentioning

confidence: 99%

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

Kallet

2015

Respir Care

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“…Subglottic secretion drainage (SSD) reduces VAP diagnoses but does not reduce time to extubation or mortality rates [5]. Persistently low tracheal cuff pressures are a risk factor for VAP but automated cuff pressure control devices have yielded conflicting results [6,7]. Tapered and polyurethane cuffs decrease (but do not eliminate) leakage around the cuff in bench studies but have not reduced VAP rates in randomized controlled trials [8,9].…”

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confidence: 99%

Beware the siren’s song of novel endotracheal tube designs

Branson

2017

Intensive Care Med

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Ventilator-associated pneumonia (VAP) remains a common and morbid complication of mechanical ventilation. Notwithstanding hospitals' and device manufacturers' extensive efforts to prevent this condition, clinical audits suggest VAP rates have changed little over the past decade [1]. VAP's persistence compels us to redouble our efforts to find better ways to prevent this condition. Prevention efforts to date can be divided into two major domains: (1) technical innovations to reduce biofilm accumulation and passage of secretions around the endotracheal tube cuff, and (2) adaptive work to minimize duration of mechanical ventilation and thus time at risk for VAP. Examples of technical innovations include antiseptic-coatings, subglottic secretion drainage, tracheal cuff pressure maintenance systems, and novel endotracheal tube cuff designs. Examples of adaptive efforts include minimizing sedation, increasing the use of spontaneous awakening and spontaneous breathing trials, and early mobilization programs.Technical innovations have followed a familiar pattern. Initially promising bench studies have given way to disappointing clinical trials [2]. Antiseptic coating decreased endotracheal tube colonization rates in sheep but did not decrease duration of mechanical ventilation or mortality rates in humans [3,4]. Subglottic secretion drainage (SSD) reduces VAP diagnoses but does not reduce time to extubation or mortality rates [5]. Persistently low tracheal cuff pressures are a risk factor for VAP but automated cuff pressure control devices have yielded conflicting results [6,7]. Tapered and polyurethane cuffs decrease (but do not eliminate) leakage around the cuff in bench studies but have not reduced VAP rates in randomized controlled trials [8,9].A recent article by Jaillette and colleagues in Intensive Care Medicine continues this disappointing pattern [10]. The investigators compared conical polyvinylchloride cuffs to standard-shaped cuffs on aspiration rates, VAP, and ventilator-associated events (VAE), and assayed endotracheal tube aspirates for pepsin and alpha-amylase. Pepsin was considered a surrogate marker for aspirating gastric fluids and alpha-amylase a surrogate marker for aspirating oropharyngeal fluids. The investigators found no difference in the frequency of positive pepsin assays (54% of tapered cuff samples vs 51% of standard cuff samples) or positive alpha-amylase assays (77 vs 69%). Likewise, there were no differences in VAP or VAE rates, ventilator-free days, ICU length-of-stay, or ICU mortality. This multicenter, cluster, randomized cross-over trial has a number of strengths. The primary outcome was positive pepsin assays, but to their credit the authors also reported on VAP, VAE, ventilator-free days, ICU lengthof-stay, and ICU mortality. Including these secondary outcomes provides useful clinical context to interpret the pepsin and alpha-amylase assays, especially since they are imperfect markers for aspiration [11].A number of important observations and questions arise from the study. First, i...

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“…A recent randomized study of 122 patients showed lower levels of pepsin in the tracheal aspirates of the group treated with a device maintaining the cuff pressure constant, confi rming the eff ectiveness of these devices in reducing micro-aspiration. Moreover, the treat ment group had lower VAP rate as compared to controls, with no evident adverse eff ects [20].…”

Section: Cuff Carementioning

confidence: 85%

Novel Preventive Strategies for Ventilator-associated Pneumonia

Coppadoro¹,

Bittner²

2012

Annual Update in Intensive Care and Emergency Medicine 2012

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Ventilator-associated pneumonia (VAP) is a complication of mechanical ventilation and is defi ned as the occurrence of pneumonia in patients undergoing mechanical ventilation for at least 48 hours. Clinical suspicion of VAP arises when new infi ltrates are present on chest x-ray, and at least one of the following is present: Fever, leukocytosis, or purulent tracheo-bronchial secretions.Th e incidence of VAP reported in the literature ranges from 15 to 20% [1]. However, the real incidence of VAP is diffi cult to assess, given the extreme variability of the diagnostic criteria for pneumonia, which often rely on broncho scopic procedures. Th e specifi c mortality attribu table to VAP is also debated. Th e reported VAPassociated mortality ranges from 20 to 70%. Patients with VAP are often critically ill, and survival may be aff ected both by underlying conditions and the new-onset VAP. A recent study demonstrated a relatively limited attributable intensive care unit (ICU)-mortality of VAP, about 1-1.5%, when adjusting for severity of co-existing diseases [2]. In the last few years, various strategies have been investigated in order to reduce the incidence of VAP. Reducing the duration of intubation, oral and endotracheal tube (ETT) care, positioning, and ETT modifi cations are aspects that may have a role in the prevention of VAP. Many of these strategies have been incorporated into 'VAP bundles' , a set of treatments implemented simultaneously to reduce VAP incidence. Recent studies suggest that the use of bundle treatments can result in substantial reductions in rates of VAP [3].In this chapter, we will present some novel VAP prevention strategies, explaining the possible mechanisms by which they may be clinically benefi cial in reducing the incidence of VAP. A summary of these novel strategies is given in Table 1. Reduce duration of intubationTh e risk of developing VAP increases with prolonged intu bation, and reintubation is a known risk factor [4]. Th is fact suggests that the presence of the ETT, although necessary for the survival of the patient, interferes with the normal physiological mechanisms that maintain the airways free of bacterial contamination. When the ETT is in place, the cough refl ex is impaired and normal mucociliary fl ow is blocked by the infl ated cuff . Th e ETT itself allows bacteria to drain into the trachea and distal airways leading to pneumonia. Intubated patients may be more prone to develop VAP as compared to tracheostomized patients because the ETT keeps the trachea and the oropharynx in communication, acting as a bridge for bacteria to move toward the dependent airways. Aspiration of pathogens from the oropharynx in patients with subglottic dysfunction may occur both during extubation and reintubation. Th e rate of reintubation can be reduced by a variety of measures, including avoiding accidental removal of the ETT, improving planned extubations with weaning protocols designed to improve extubation success, and use of non-invasive ventilation (NIV).On the basis of the observatio...

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Continuous Control of Tracheal Cuff Pressure and Microaspiration of Gastric Contents in Critically Ill Patients

Abstract: Continuous control of P(cuff) is associated with significantly decreased microaspiration of gastric contents in critically ill patients.

Cited by 206 publications

References 45 publications

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

Beware the siren’s song of novel endotracheal tube designs

Novel Preventive Strategies for Ventilator-associated Pneumonia

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