Prevention of Ventilator-Associated and Early Postoperative Pneumonia Through Tapered Endotracheal Tube Cuffs: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Maertens, Bert; Blot, Koen; Blot, Stijn

doi:10.1097/ccm.0000000000002889

Cited by 34 publications

(27 citation statements)

References 47 publications

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“…The use of specific, targeted polymerase chain reaction (PCR) may allow shortening this time to 24-36 h., but for specific pathogens and specific resistance mechanisms. A potential future workup process will be to use multiplex PCR (blue box) to identify within less than 6 h pathogens responsible for VAP and their resistance to antimicrobials chloride at preventing VAP or improving objective outcomes [101][102][103][104]. Likewise, manually monitoring cuff pressures every 8 h to minimize inadvertent drops in endotracheal tube cuff pressure was no better at preventing VAP, decreasing length-of-stay, or lowering mortality in a recent single center study compared to checking cuff pressures only at intubation, following frank tube migration, or detection of a cuff pressure leak [105].…”

Section: In Intubated Patients Suspected Of Having Vap Should Distalmentioning

confidence: 99%

“…Head-of-bed elevation [116] May lower rates Understudied, few and contradictory randomized trials Tapered endotracheal tube cuffs and ultrathin polyurethane [102,104] No impact In vivo studies document persistently high rates of subclinical aspiration despite the theoretical advantages of these designs Automated endotracheal tube cuff pressure monitoring [106] May lower rates Understudied, merits further evaluation [92,123,125] May increase VAP rates Observational studies and some meta-analyses suggest higher VAP rates but a recent large randomized trial found no impact VAP prevention bundles [128] Likely lower VAP rates Extensively studied, almost exclusively in before-after and time-series analyses. May be associated with lower mortality rates.…”

Section: Intervention Probable Impact On Vap Rates Commentsmentioning

confidence: 99%

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Ventilator-associated pneumonia in adults: a narrative review

Papazian¹,

2020

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Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative.

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Section: In Intubated Patients Suspected Of Having Vap Should Distalmentioning

confidence: 99%

Section: Intervention Probable Impact On Vap Rates Commentsmentioning

confidence: 99%

Ventilator-associated pneumonia in adults: a narrative review

Papazian¹,

2020

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“…Preventive strategies mainly target optimization of basic infection control measures, avoidance of delayed extubation, biofilm formation on the endotracheal tube and of micro-aspiration of subglottic secretions, prevention of bacterial translocation from stomach to oropharynx, and modulation of oropharyngeal colonization [4–8]. Regarding the last of these, the value of chlorhexidine oral care has been studied extensively.…”

Section: Introductionmentioning

confidence: 99%

Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide, observational cohort study

et al. 2018

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PurposeChlorhexidine oral care is widely used in critically and non-critically ill hospitalized patients to maintain oral health. We investigated the effect of chlorhexidine oral care on mortality in a general hospitalized population.MethodsIn this single-center, retrospective, hospital-wide, observational cohort study we included adult hospitalized patients (2012–2014). Mortality associated with chlorhexidine oral care was assessed by logistic regression analysis. A threshold cumulative dose of 300 mg served as a dichotomic proxy for chlorhexidine exposure. We adjusted for demographics, diagnostic category, and risk of mortality expressed in four categories (minor, moderate, major, and extreme).ResultsThe study cohort included 82,274 patients of which 11,133 (14%) received chlorhexidine oral care. Low-level exposure to chlorhexidine oral care (≤ 300 mg) was associated with increased risk of death [odds ratio (OR) 2.61; 95% confidence interval (CI) 2.32–2.92]. This association was stronger among patients with a lower risk of death: OR 5.50 (95% CI 4.51–6.71) with minor/moderate risk, OR 2.33 (95% CI 1.96–2.78) with a major risk, and a not significant OR 1.13 (95% CI 0.90–1.41) with an extreme risk of mortality. Similar observations were made for high-level exposure (> 300 mg). No harmful effect was observed in ventilated and non-ventilated ICU patients. Increased risk of death was observed in patients who did not receive mechanical ventilation and were not admitted to ICUs. The adjusted number of patients needed to be exposed to result in one additional fatality case was 47.1 (95% CI 45.2–49.1).ConclusionsThese data argue against the indiscriminate widespread use of chlorhexidine oral care in hospitalized patients, in the absence of proven benefit in specific populations.Electronic supplementary materialThe online version of this article (10.1007/s00134-018-5171-3) contains supplementary material, which is available to authorized users.

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“…Maertens and colleagues further evaluated tapered versus conventional cuffs by combining these two trials with four others (total 1,324 patients). 60 On meta-analysis, they found no difference between cuff shapes in the frequency of hospital-acquired pneumonia nor any signals in the individual studies suggesting differences in duration of mechanical ventilation (three trials), ICU length of stay (four trials), or mortality (three trials). There is a paucity of additional studies on polyurethane cuffs that include data on clinical outcomes, but for the present at least there is no clear signal of clinical benefit.…”

Section: Endotracheal Tube Cuff Design and Pressure Monitoringmentioning

confidence: 95%

Prevention of Intensive Care Unit-Acquired Pneumonia

Klompas

2019

Semin Respir Crit Care Med

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Intensive care unit (ICU) acquired pneumonia is one of the most common and morbid health care-associated infections. Despite decades of work developing and testing prevention strategies, ICU-acquired pneumonia remains stubbornly pervasive. Pneumonia prevention studies are difficult to interpret because all are at risk of bias due to the subjectivity and poor specificity of pneumonia definitions. Interventions associated with improvements in objective outcomes in addition to pneumonia, such as length of stay or mortality, should therefore be prioritized. Avoiding intubation, minimizing sedation, implementing early extubation strategies, and mobilizing patients do appear to improve some of these objective outcomes. Many of our other assumptions about how best to prevent ICU-acquired pneumonia, however, have recently been challenged. Elevating the head of the bed is supported by very little randomized trial data. Early reports suggested that subglottic secretion drainage may decrease time to extubation and ICU length of stay, but more recent analyses refute these findings. Novel endotracheal tube cuff designs do not clearly lower pneumonia rates. A large randomized trial of selective digestive decontamination in ICUs with high baseline rates of antimicrobial resistance did not identify any benefit. Oral care with chlorhexidine may increase mortality risk and stress ulcer prophylaxis may facilitate pneumonia. Early data on probiotics suggest a possible effect but there is no clear signal yet that they shorten duration of mechanical ventilation or lower mortality. Ventilator bundles on balance do appear to be beneficial but it is not clear which components are most important nor how best to implement them. This article will review recent studies that have challenged, refined, or complicated our understanding of how best to prevent ICU-acquired pneumonia.

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Prevention of Ventilator-Associated and Early Postoperative Pneumonia Through Tapered Endotracheal Tube Cuffs: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Cited by 34 publications

References 47 publications

Ventilator-associated pneumonia in adults: a narrative review

Ventilator-associated pneumonia in adults: a narrative review

Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide, observational cohort study

Prevention of Intensive Care Unit-Acquired Pneumonia

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