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Chest: Postgraduate Education Corner
Chest: Postgraduate Education Corner
Ventilator-associated pneumonia (VAP) is associated with high morbidity, mortality, and costs.
Interventions to prevent VAP are a high priority in the care of critically ill patients requiring
mechanical ventilation (MV). Multiple interventions are recommended by evidence-based prac-
tice guidelines to prevent VAP, but there is a growing interest in those related to the endotracheal
tube (ETT) as the main target linked to VAP. Microaspiration and biofilm formation are the two
most important mechanisms implicated in the colonization of the tracheal bronchial tree and the
development of VAP. Microaspiration occurs when there is distal migration of microorganisms
present in the secretions accumulated above the ETT cuff. Biofilm formation has been described
as the development of a network of secretions and attached microorganisms that migrate along
the ETT cuff polymer and inside the lumen, facilitating the transfer to the sterile bronchial tree.
Therefore, our objective was to review the literature related to recent advances in ETT technol-
ogies regarding their impact on the control of microaspiration and biofilm formation in patients
on MV, and the subsequent impact on VAP. CHEST 2012; 142(1):231–238
Abbreviations: ETT 5 endotracheal tube; HVLP 5 high-volume low-pressure; MV 5 mechanical ventilation; PUC 5 poly-
urethane cuff; RR 5 relative risk; SSD 5 subglottic secretion drainage; VAP 5 ventilator-associated pneumonia
journal.publications.chestnet.org
Study/Year Country Population Studied Type of Study Intervention ETT Control ETT VAP Definition Outcomes
11
Vallés et al /1995 Spain Medical-surgical ICU patients Randomized controlled SSD Non-SSD Clinical and microbiologic
on MV for . 72 h confirmation of VAP
Zhenq et al12/2008 China Patients on MV for . 48 h Retrospective controlled SSD Non-SSD Clinical confirmation of VAP
Mahul et al13/1992 France Medical-surgical ICU patients Randomized controlled SSD Non-SSD Clinical and microbiologic
on MV for . 72 h confirmation of VAP
Bo et al14/2000 China Surgical ICU patients on MV Randomized controlled SSD (CASS) Non-SSD Clinical and microbiologic
for . 72 h confirmation of VAP
Kollef et al15/1999 United States Cardiothoracic ICU patients Prospective randomized SSD (CASS) Non-SSD Clinical confirmation of VAP
on MV after cardiac surgery clinical
Girou et al16/2004 France Patients intubated for . 5 d Randomized controlled SSD (CASS) Non-SSD Clinical and microbiologic
confirmation of VAP
Bouza et al17/2008 Spain Patients with major heart surgery Randomized controlled SSD (CASS) Non-SSD Clinical and microbiologic
confirmation of VAP
Yang et al18/2008 China Patients on MV for . 48 h Randomized controlled SSD (CASS) Non-CASS Clinical confirmation of VAP
Smulders et al19/2002 The Netherlands Medical-surgical ICU patients on Randomized controlled SSD (intermittent suction) Non-SSD Clinical confirmation of VAP
MV for . 72 h
Lacherade et al20/2010 France Patients on MV for . 48 h Randomized controlled SSD (intermittent suction) Non-SSD Clinical and microbiologic
confirmation of VAP
Lorente et al21/2007 Spain Patients on MV for . 24 h Clinical randomized SSD/tapered-shaped PU cuff Non-SSD Clinical and microbiologic
(intermittent drainage) PVC cuff confirmation of VAP
Poelaert et al22/2008 Belgium Postoperative cardiac surgery Prospective single-blind Tapered-shaped PU cuff PVC cuff Clinical confirmation VAP
randomized
Miller et al23/2011 United States Adults in ICU intubated Observational Cylindric PU cuff PVC cuff Clinical and microbiologic
confirmation of VAP
Kollef et al24/2008 United States Patients on MV for . 24 h Prospective randomized Silver-coated cuff Non-silver-coated Clinical and microbiologic
single-blind controlled PVC cuff confirmation of VAP
CASS 5 continuous aspiration of subglottic secretions; ETT 5 endotracheal tube; MV 5 mechanical ventilation; PU 5 polyurethane; PVC 5 polyvinylchloride; SSD 5 subglottic secretion drainage;
VAP 5 ventilator-associated pneumonia.
Centers, Total Intervention ETT, No. (%) Control ETT, No. (%)
Study/Year No. Patients, No. [Rate per 1,000 Vent-d] [Rate per 1,000 Vent-d] P Value Conclusions
Vallés et al /1995
11 1 153 14/76 (18.4) [19.9] 25/77 (32.5) [39.6] .07 Decreasing trend in NP
Zhenq et al12/2008 NA 61 9/30 (30) 16/31(51) , .05 Decrease in VAP
Mahul et al13/1992 1 145 9/70 (12) 21/75 (29) , .05 Decrease in NP
Bo et al14/2000 NA 68 35 (23) 33 (45) , .05 Decrease in VAP
Kollef et al15/1999 1 343 8/160 (5) [34.5] 15/183 (8.2) [43.2] .2 Delaying trend to VAP
Girou et al16/2004 1 18 5/8 (62) 6/10 (60) .6 No modification of tracheal
colonization by intervention
and semirecumbent body
position
Bouza et al17/2008 1 690 12/331 (3.6) [17.9] 19/359 (5.3) [27.6] 0.2 Decreasing trend in VAP
Yang et al18/2008 NA 91 12/48 (25) 20/43 (46.5) .03 Decrease in VAP
Smulders et al19/2002 1 105 2/49 (4.1) [6.4] 10/56 (17.9) [21.3] .02 Decrease in VAP
, .001
Lacherade et al20/2010 4 333 25/169 (14.8) [17] 42/164 (25.6) [34] .002 Decrease in VAP
.02
Lorente et al21/2007 1 280 11/140 (7.9) [7.5] 31/140 (22.1) [19.9] .001 Decrease in early- and
late-onset VAP
Poelaert et al22/2008 1 134 15/67 (23) 28/67 (42) .02 Decrease in VAP
Miller et al23/2011 1 135 21/7,545a [2.8] 43/8,678a [5.3] , .03 Decrease in VAP
.014
Kollef et al24/2008 54 1,509 37/766 (4.8) 56/743 (7.5) .03 Decrease in VAP
NA 5 not available; NP 5 nosocomial pneumonia; Vent-d 5 ventilator-days. See Table 1 for expansion of other abbreviations.
aVentilator-days.
which a negative pressure is applied in order to aspi- Another concern related to the use of SSD was the
rate the secretions. Some examples of this type of possibility of developing tracheal injury, because of
ETT design are the Hi-Lo Evac tube and the Seal the proximity of the subglottic suction port to the
Guard or Taper Guard (Covidien). The outcomes in tracheal mucosa, as suggested in animal studies.39
VAP prevention with SSD are conflicting, with some However, the Hi-Lo Evac tubes decreased the space
studies showing reduction in VAP incidence,12-14,19 between the upper portion of the cuff and the suc-
others suggesting a prolongation of the period of time tion port, in an attempt to limit the development of
to the development of VAP,11,13-15,19,36 and still others tracheal injury. Similarly, LowTrach tubes, which
showing a lack of efficacy of SSD to reduce VAP30 incorporate three suction ports close to the ETT cuff,
or airway colonization.16 may prevent aspiration and have less tracheal mucosa
The benefit of SSD has been reported in two injury by avoiding continuous suctioning (multiple
recent meta-analyses.7,37 Muscedere et al37 evaluated suction ports present). Nevertheless, this ETT has a
2,442 patients from 13 randomized controlled trials, higher cost and limited clinical data are available.36
showing a reduction of 50% in the risk of acquiring Determining the best method for delivering SSD
VAP (overall risk ratio, 0.55; 95% CI, 0.46-0.66; is still a matter of controversy. There is evidence that
P , .00001) and possible reduction in duration of patients with signs of subglottic aspiration failure do
MV (21.08 days; 95% CI, 22.04 to 20.12; P 5 .03) not have increased mortality, prolonged duration of
and ICU length of stay (21.52 days; 95% CI, 22.94 MV, or prolonged ICU or hospital stays.11,15,19 The use
to 0.11; P 5 .03), but no reduction in mortality. Iden- of continuous SSD has been recommended for patients
tical VAP reduction findings were reported previ- on MV for . 72 h or for those undergoing major heart
ously in a smaller meta-analysis by Dezfulian et al,7 surgery.7,17 Current guidelines recommend the use
mainly by reduction of pneumonia during the first of SSD to reduce early- and late-onset VAP2,4; how-
5 to 7 days after intubation (summary risk ratio, 0.51; ever, there is no difference in VAP reduction when
95% CI, 0.37- 0.71). However, Rello et al30 raised the comparing continuous (RR, 0.50; 95% CI, 0.37-0.66)
concern that a mechanical failure of SSD was evi- and intermittent ( RR, 0.59; 95% CI, 0.47-0.74) suc-
dent in one-third of patients, adding to the risk fac- tion.37 A risk-benefit analysis should be considered
tors associated with the development of VAP. They when making the decision about using either tech-
hypothesized that SSD failure was related to block- nique of SSD. Although lower risk of harm (eg, tra-
age of the subglottic suction port secondary to suc- cheal injury and so forth)21 is theoretically possible
tioned tracheal mucosa, as observed under flexible with intermittent SSD, a direct comparison with con-
bronchoscopy.30,38 tinuous suction has not been done, and the optimal