Investigating the Failure to Aspirate Subglottic Secretions with the Evac Endotracheal Tube

Dragoumanis, Christos; Vretzakis, George; Papaioannou, Vasilios; Didilis, Vassilios; Vogiatzaki, Theodsia D.; Pneumatikos, Ioannis

doi:10.1213/01.ane.0000278155.19911.67

Cited by 50 publications

(40 citation statements)

References 10 publications

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“…A systematic review of 17 eligible trials with 3,369 subjects showed that subglottic secretion drainage tubes helped to reduce VAP rates. 5 However, the reported failure to aspirate subglottic secretions using subglottic secretion drainage had an incidence of 34% in the study by Rello et al 6 and 48% in the study by Dragoumanis et al 7 This high incidence of failure raised safety concerns with subglottic secretion drainage, because the suction port was apparently occluded by suctioned tracheal mucosa, 7 which was the dominant cause of suction lumen dysfunction and a cause of the tracheal membrane injury 8 and laryngeal edema. 9 Other ways have been sought to clear subglottic secretions, such as utilization of high PEEP or plateau pressure generated by a ventilator.…”

Section: See the Related Editorial On Page 1111mentioning

confidence: 99%

Evaluation of the Safety and Effectiveness of the Rapid Flow Expulsion Maneuver to Clear Subglottic Secretions in Vitro and in Vivo

Zong

Zhou

et al. 2017

Respir Care

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BACKGROUND: Clearing subglottic secretions has been proved to reduce ventilator-associated pneumonia. A manual method named the rapid flow expulsion maneuver was developed to clear subglottic secretions. This study evaluates its safety and effectiveness and analyzes the influential factors. METHODS: This study was composed of 2 parts. In an in vitro study, secretions were instilled directly to the area above the cuff in an intubated tracheal model. Secretions were expelled by the rapid flow expulsion maneuver with different volumes and peak flows in 3 tracheal positions (0, 15, and 30°). At each tracheal position, the maneuver was repeated twice, unless secretions above the cuff were <0.5 mL. In an in vivo study, subglottic secretions were suctioned via subglottic secretion drainage and then were cleared by the rapid flow expulsion maneuver. After the initial maneuver, methylene blue (2 mL) was instilled above the cuff, and the maneuver was performed again. The subject's sputum color was then recorded over 24 h. RESULTS: In the in vitro study, no aspiration was observed in the 277 maneuvers completed. Subglottic secretions were visibly expelled in 167 of 277 maneuvers (60.3%), and the median clearance efficiencies of the 3 consecutive maneuvers were 39.6, 6.3, and 0.4%. In the 108 first maneuvers, 93 (86.1%) produced visible secretions. Multiple linear regression models were used to identify predictors of clearance efficiency: tracheal position (P < .001), flow (P ‫؍‬ .041), and secretion viscosity (P ‫؍‬ .017). In the in vivo study, 77 rapid flow expulsion maneuvers were completed after suctioning via subglottic secretion drainage in 16 subjects, and the maneuvers collected 221.5 mL of secretions. No aspiration was observed over 24 h. CONCLUSIONS: The rapid flow expulsion maneuver was safe and effective to clear subglottic secretions. The first maneuver was the most effective to expel the majority of secretions. Supine position and high peak flow improved the clearance efficiency.

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Section: See the Related Editorial On Page 1111mentioning

confidence: 99%

Evaluation of the Safety and Effectiveness of the Rapid Flow Expulsion Maneuver to Clear Subglottic Secretions in Vitro and in Vivo

Zong

Zhou

et al. 2017

Respir Care

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“…In 17 of the 19 failures, bronchoscopy determined that the subglottic suction lumen was blocked by tracheal mucosa; one subject had a mucus plug, and the other was undetermined due to poor bronchoscopic visibility. 144 Harvey et al 145 reported 2 cases of tracheoesophageal fistula that appeared to be in the vicinity of the SSD suction port. Another study using continuous aspiration of subglottic secretions reported a 40% incidence of postextubation laryngeal edema and considered it an adverse outcome of SSD.…”

Section: Subglottic Secretion Drainagementioning

confidence: 99%

Endotracheal Tubes: Old and NewDiscussion

et al. 2014

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The development and evolution of the endotracheal tube (ETT) have been closely related to advances in surgery and anesthesia. Modifications were made to accomplish many tasks, including minimizing gross aspiration, isolating a lung, providing a clear facial surgical field during general anesthesia, monitoring laryngeal nerve damage during surgery, preventing airway fires during laser surgery, and administering medications. In critical care management, ventilator-associated pneumonia (VAP) is a major concern, as it is associated with increased morbidity, mortality, and cost. It is increasingly appreciated that the ETT itself is a primary causative risk for developing VAP. Unfortunately, contaminated oral and gastric secretions leak down past the inflated ETT cuff into the lung. Bacteria can also grow within the ETT in biofilm and re-enter the lung. Modifications to the ETT that attempt to prevent bacteria from entering around the ETT include maintaining an adequate cuff pressure against the tracheal wall, changing the material and shape of the cuff, and aspirating the secretions that sit above the cuff. Attempts to reduce bacterial entry through the tube include antimicrobial coating of the ETT and mechanically scraping the biofilm from within the ETT. Studies evaluating the effectiveness of these modifications and techniques demonstrate mixed results, and clear recommendations for which modification should be implemented are weak.

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“…The optimal suction pressure is between 20 and 30 mmHg but the clinical variation should be considered, those pressures are sufficient to keep the suction efficient in removing the subglottic secretion specially when there is a viscoid secretion [40], the suction may be continuous or intermittent, it has been proved that both continuous and intermittent has the same effects in the prevention of VAP [35,36], the continuous suction has problems with the mucosa causing herniation of the of the tracheal mucosa into the suction part leading to block of the suction system especially with high suction pressure [41]. While the intermittent suction is better in the mucosal injury, although in the time between the suctions, there may be some leakage between the folds of the cuff and the tracheal causing late onset VAP.…”

Section: Subglottic Secretion Drainage (Ssd)mentioning

confidence: 99%

Prevention of Ventilation Associated Pneumonia, New Ideas and Better Results

2015

J Pulm Respir Med

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The ventilation associated pneumonia is one the biggest challenge in the critical care team. It has a high mortality rate and an increase cost of the management. The use of the antibiotics did not show a great improvement in the survival rate. On the other hand, the prevention of ventilation associated pneumonia shows promising results, it improves the survival rate, decease both days of antibiotic use and days in the critical care unit. In the last 10 years, different methods used for the prevention of ventilator associated pneumonia. Some of those methods show a promising results while others need do not.We reviewed different methods of prevention including oral hygiene, probiotics, cuff pressure control, subglottic secretion drainage, endotracheal cuff, coated endotracheal tube, and the multisystem approach. We review the papers and the data supplement online, and we compared between the different methods in the short outcome, long outcome, length of stay in the ICU, and the cost of the management.

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Investigating the Failure to Aspirate Subglottic Secretions with the Evac Endotracheal Tube

Abstract: Evacuation of subglottic secretions using the Evac ETT is often ineffective due to prolapse of tracheal mucosa into the subglottic suction port.

Cited by 50 publications

References 10 publications

Evaluation of the Safety and Effectiveness of the Rapid Flow Expulsion Maneuver to Clear Subglottic Secretions in Vitro and in Vivo

Evaluation of the Safety and Effectiveness of the Rapid Flow Expulsion Maneuver to Clear Subglottic Secretions in Vitro and in Vivo

Endotracheal Tubes: Old and NewDiscussion

Prevention of Ventilation Associated Pneumonia, New Ideas and Better Results

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