Effectiveness of Continuous Cuff Pressure Control in Preventing Ventilator-Associated Pneumonia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Journal
Critical care medicine
ISSN: 1530-0293
Titre abrégé: Crit Care Med
Pays: United States
ID NLM: 0355501
Informations de publication
Date de publication:
01 10 2022
01 10 2022
Historique:
pubmed:
27
7
2022
medline:
20
9
2022
entrez:
26
7
2022
Statut:
ppublish
Résumé
Microaspiration of subglottic secretions is the main pathogenic mechanism for ventilator-associated pneumonia (VAP). Adequate inflation of the endotracheal cuff is pivotal to providing an optimal seal of the extraluminal airway. However, cuff pressure substantially fluctuates due to patient or tube movements, which can induce microaspiration. Therefore, devices for continuous cuff pressure control (CCPC) have been developed in recent years. The purpose of this systematic review and meta-analysis is to assess the effectiveness of CCPC in VAP prevention. A systematic search of Embase, the Cochrane Central Register of Controlled Trials, and the International Clinical Trials Registry Platform was conducted up to February 2022. Eligible studies were randomized controlled trials (RCTs) and quasi-RCTs comparing the impact of CCPC versus intermittent cuff pressure control on the occurrence of VAP. Random-effects meta-analysis was used to calculate odds ratio (OR) and 95% CI for VAP incidence between groups. Secondary outcome measures included mortality and duration of mechanical ventilation (MV) and ICU stay. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. Eleven RCTs with 2,092 adult intubated patients were included. The use of CCPC was associated with a reduced risk of VAP (OR, 0.51). Meta-analyses of secondary endpoints showed no significant difference in mortality but significant differences in durations of MV (mean difference, -1.07 d) and ICU stay (mean difference, -3.41 d) in favor of CCPC. However, the risk of both reporting and individual study bias was considered important. The main issues were the lack of blinding, potential commercial conflicts of interest of study authors and high heterogeneity due to methodological differences between studies, differences in devices used for CCPC and in applied baseline preventive measures. Certainty of the evidence was considered "very low." The use of CCPC was associated with a reduction in VAP incidence; however, this was based on very low certainty of evidence due to concerns related to risk of bias and inconsistency.
Identifiants
pubmed: 35880890
doi: 10.1097/CCM.0000000000005630
pii: 00003246-202210000-00002
doi:
Types de publication
Journal Article
Meta-Analysis
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
1430-1439Commentaires et corrections
Type : CommentIn
Informations de copyright
Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Déclaration de conflit d'intérêts
Dr. Rello disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest. Eleven RCTs with 2,092 adult intubated patients were included. The use of CCPC was associated with a reduced risk of VAP (OR, 0.51). Meta-analyses of secondary endpoints showed no significant difference in mortality but significant differences in durations of MV (mean difference, –1.07 d) and ICU stay (mean difference, –3.41 d) in favor of CCPC. However, the risk of both reporting and individual study bias was considered important. The main issues were the lack of blinding, potential commercial conflicts of interest of study authors and high heterogeneity due to methodological differences between studies, differences in devices used for CCPC and in applied baseline preventive measures. Certainty of the evidence was considered “very low.”
Références
Blot S, Koulenti D, Dimopoulos G, et al.; EU-VAP Study Investigators: Prevalence, risk factors, and mortality for ventilator-associated pneumonia in middle-aged, old, and very old critically ill patients*. Crit Care Med 2014; 42:601–609
Kollef MH, Hamilton CW, Ernst FR: Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol 2012; 33:250–256
Melsen WG, Rovers MM, Groenwold RH, et al.: Attributable mortality of ventilator-associated pneumonia: A meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis 2013; 13:665–671
Blot S, Ruppé E, Harbarth S, et al.: Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies. Intensive Crit Care Nurs 2022; 70:103227
Chan EY, Ruest A, Meade MO, et al.: Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review and meta-analysis. BMJ 2007; 334:889
Labeau SO, Van de Vyver K, Brusselaers N, et al.: Prevention of ventilator-associated pneumonia with oral antiseptics: A systematic review and meta-analysis. Lancet Infect Dis 2011; 11:845–854
Wang F, Bo L, Tang L, et al.: Subglottic secretion drainage for preventing ventilator-associated pneumonia: An updated meta-analysis of randomized controlled trials. J Trauma Acute Care Surg 2012; 72:1276–1285
Mao Z, Gao L, Wang G, et al.: Subglottic secretion suction for preventing ventilator-associated pneumonia: An updated meta-analysis and trial sequential analysis. Crit Care 2016; 20:353
Safdar N, Crnich CJ, Maki DG: The pathogenesis of ventilator-associated pneumonia: Its relevance to developing effective strategies for prevention. Respir Care 2005; 50:725–39
Zolfaghari PS, Wyncoll DL: The tracheal tube: Gateway to ventilator-associated pneumonia. Crit Care 2011; 15:310
Kollef MH: Prevention of postoperative pneumonia. Hosp Physician 2007; 64:47–60
Masterton RG, Galloway A, French G, et al.: Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2008; 62:5–34
Muscedere J, Dodek P, Keenan S, et al.; VAP Guidelines Committee and the Canadian Critical Care Trials Group: Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention. J Crit Care 2008; 23:126–137
Rose L, Redl L: Survey of cuff management practices in intensive care units in Australia and New Zealand. Am J Crit Care 2008; 17:428–435
Sole ML, Byers JF, Ludy JE, et al.: A multisite survey of suctioning techniques and airway management practices. Am J Crit Care 2003; 12:220–30
Danielis M, Benatti S, Celotti P, et al.: [Continuous monitoring of endotracheal tube cuff pressure: Best practice in intensive care unit]. Assist Inferm Ric 2015; 34:15–20
Sole ML, Penoyer DA, Su X, et al.: Assessment of endotracheal cuff pressure by continuous monitoring: A pilot study. Am J Crit Care 2009; 18:133–143
Nseir S, Brisson H, Marquette CH, et al.: Variations in endotracheal cuff pressure in intubated critically ill patients: Prevalence and risk factors. Eur J Anaesthesiol 2009; 26:229–234
Lizy C, Swinnen W, Labeau S, et al.: Cuff pressure of endotracheal tubes after changes in body position in critically ill patients treated with mechanical ventilation. Am J Crit Care 2014; 23:e1–e8
Michikoshi J, Matsumoto S, Miyawaki H, et al.: Performance comparison of a new automated cuff pressure controller with currently available devices in both basic research and clinical settings. J Intensive Care 2016; 4:4
Jaillette E, Zerimech F, De Jonckheere J, et al.: Efficiency of a pneumatic device in controlling cuff pressure of polyurethane-cuffed tracheal tubes: A randomized controlled study. BMC Anesthesiol 2013; 13:50
Farré R, Rotger M, Ferre M, et al.: Automatic regulation of the cuff pressure in endotracheally-intubated patients. Eur Respir J 2002; 20:1010–1013
Nseir S, Duguet A, Copin MC, et al.: Continuous control of endotracheal cuff pressure and tracheal wall damage: A randomized controlled animal study. Crit Care 2007; 11:R109
Duguet A, D’Amico L, Biondi G, et al.: Control of tracheal cuff pressure: A pilot study using a pneumatic device. Intensive Care Med 2007; 33:128–132
Kunitz O, Jansen R, Ohnsorge E, et al.: [Cuff pressure monitoring and regulation in adults]. Anaesthesist 2004; 53:334–340
Chenelle CT, Oto J, Sulemanji D, et al.: Evaluation of an automated endotracheal tube cuff controller during simulated mechanical ventilation. Respir Care 2015; 60:183–190
Brisson H, Bouhemad B, Lu Q, et al.: Comparison of two automated endotracheal cuff pressure regulators devices in intubated critically ill patients: Mechanical and electronic. Intensive Care Med 2011; 37:S79
Nseir S, Zerimech F, Fournier C, et al.: Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am J Respir Crit Care Med 2011; 184:1041–1047
Nseir S, Lorente L, Ferrer M, et al.: Continuous control of tracheal cuff pressure for VAP prevention: A collaborative meta-analysis of individual participant data. Ann Intensive Care 2015; 5:43
Valencia M, Ferrer M, Farre R, et al.: Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: A randomized trial. Crit Care Med 2007; 35:1543–1549
Lorente L, Lecuona M, Jiménez A, et al.: Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia. Crit Care 2014; 18:R77
Page MJ, McKenzie JE, Bossuyt PM, et al.: The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021; 372:n71
Glanville JM, Duffy S, McCool R, et al.: Searching ClinicalTrials.gov and the International Clinical Trials Registry Platform to inform systematic reviews: What are the optimal search approaches? J Med Libr Assoc 2014; 102:177–183
Tai FM, Willson ML, Ghersi D: Implications of searching multiple trial registries: How should we search ClinicalTrials.gov and WHO ICTRP?. In: Abstracts of the 20th Cochrane Colloquium; Sept. 30-Oct. 3, 2012. Auckland, John Wiley & Sons, 2012
Craven DE, Hudcova J, Lei Y: Diagnosis of ventilator-associated respiratory infections (VARI): Microbiologic clues for tracheobronchitis (VAT) and pneumonia (VAP). Clin Chest Med 2011; 32:547–557
Sterne JAC, Savović J, Page MJ, et al.: RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366:l4898
Egger M, Davey Smith G, Schneider M, et al.: Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315:629–634
McGrath S, Zhao X, Steele R, et al.: Estimating the sample mean and standard deviation from commonly reported quantiles in meta-analysis. Stat Methods Med Res 2020; 29:2520-2537
Higgins JP, Thompson SG, Deeks JJ, et al.: Measuring inconsistency in meta-analyses. BMJ 2003; 327:557–560
Guyatt GH, Oxman AD, Kunz R, et al.: GRADE guidelines 6. Rating the quality of evidence–imprecision. J Clin Epidemiol 2011; 64:1283–1293
Wen Z, Wei L, Chen J, et al.: Is continuous better than intermittent control of tracheal cuff pressure? A meta-analysis. Nurs Crit Care 2019; 24:76–82
De Pascale G, Pennisi MA, Vallecoccia MS, et al.: CO2 driven endotracheal tube cuff control in critically ill patients: A randomized controlled study. PLoS One 2017; 12:e0175476
Muzlovic I, Perme J, Stubljar D: Orotracheal tube as a risk factor for lower respiratory tract infection: Preliminary data from a randomised trial. Wien Klin Wochenschr 2018; 130:328–334
Dauvergne JE, Geffray AL, Asehnoune K, et al.: Automatic regulation of the endotracheal tube cuff pressure with a portable elastomeric device. A randomised controlled study. Anaesth Crit Care Pain Med 2020; 39:435–441
Dat VQ, Yen LM, Loan HT, et al.: Effectiveness of continuous endotracheal cuff pressure control for the prevention of ventilator associated respiratory infections: An open-label randomised, controlled trial. Clin Infect Dis 2022; 74:1795–1803
Marjanovic N, Boisson M, Asehnoune K, et al.; AGATE Study Group: Continuous pneumatic regulation of tracheal cuff pressure to decrease ventilator-associated pneumonia in mechanically ventilated trauma patients: The AGATE multicenter randomized controlled study. Chest 2021; 160:499–508
Li W, Zhao L, Yin J: Application of self-made dynamic balloon pressure monitoring system combined with sustained low vacuum suction in artificial airway management of patients with mechanical ventilation. Chin J Mod Nurs 2012; 18:58–62
Wang H, Jiang D, Yang Z, et al.: Continuous monitoring of cuff pressure to prevent ventilator-associated pneumonia. Chin J Emerg Med 2015; 24:187–195
Yao L, Yu M, Zhu P, et al.: Effect of continuous artificial airway cuff pressure control on the incidence of ventilator-associated pneumonia. Chin J Mod Nurs 2017; 23:476-484
Lorente L, Lecuona M, Jiménez A, et al.: Subglottic secretion drainage and continuous control of cuff pressure used together save health care costs. Am J Infect Control 2014; 42:1101–1105
Dat VQ, Geskus RB, Wolbers M, et al.: Continuous versus intermittent endotracheal cuff pressure control for the prevention of ventilator-associated respiratory infections in Vietnam: Study protocol for a randomised controlled trial. Trials 2018; 19:217
Marjanovic N, Frasca D, Asehnoune K, et al.; AGATE study group: Multicentre randomised controlled trial to investigate the usefulness of continuous pneumatic regulation of tracheal cuff pressure for reducing ventilator-associated pneumonia in mechanically ventilated severe trauma patients: The AGATE study protocol. BMJ Open 2017; 7:e017003
De Pascale G, Vallecoccia MS, Giacobelli D, et al.: Preliminary results from the use of anapnoguard 100 system in intubated critical care patients. Intensive Care Med 2014; 40:S261
Blot SI, Poelaert J, Kollef M: How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients. BMC Infect Dis 2014; 14:119