Subglottic Secretion Drainage for Preventing Ventilator Associated Pneumonia: A Meta-analysis

Objective： Ventilator associated pneumonia （VAP） has been shown to be associated with significant morbidity and mortality（ Chastre and Fagon, 2002; klompas, 2007） among mechanically venti- lated patients in the intensive care unit （ICU）, with the incidence ranging from 9% to 27% ; crude mortality ranges from 25% to 50%.1-3 A meta-analysis of published studies was undertaken to combine information regarding the effect of subglottic secretion drainage （SSD） on the incidence of ventilated associated pneumonia in adult ICU patients. Methods： Reports of studies on SSD were identified by searching the PUBMED, EMBASE, and COCHRANCE LIBRARY databases （December 30, 2010）. Randomized trials of SSD compared to usual care in adult mechanically ventilated ICU patients were included in this meta-analysis. Results： Ten RCTs with 2,314 patients were identified. SSD significantly reduced the incidence of VAP [ relative risk （RR） =0.52, 95% confidence interval （C/）： 0.42-0.64, P〈0.000 01]. When SSD was compared with the control groups, the overall RR for ICU mortality was 1.00 （95% CI, 0.84-1.19） and for hospital mortality was 0.95 （95% CI, 0. 80-1.13）. Overall, the subglottic drainage effect on the days of mechanical ventilation was -1.52 days （95% CI, -2.94 to -0.11） and on the ICU length of stay （LOS） was -0.81days （95% CI, -2.33 to -0.7）. Conclusions： In this meta-analysis, when an endotracheal tube （ETT） with SSD was compared with an ETT without SSD, there was a highly significant reduction in the VAP rate of approxi- mately 50%. Time on mechanical ventilation （MV） and the ICU LOS may be reduced, but no reduction in ICU or hospital mortality has been observed in published trials,

Ventilator Associated Pneumonia in an Intensive Care Unit

The aim of this prospective study was to evaluate the incidence, etiologic agents and mortality rate of ventilator-associated pneumonia (VAP). In a six-month period, cases who were 18 years or older, dependent on mechanical ventilator for more than 3 days and without pulmonary infection on first admission were included in this study. In all cases, body temperature recordings, blood and urine culture, microbiological analyses of endotracheal aspirates, and chest X-rays were obtained and used to identify VAP. Apache II scores on admission, duration of mechanical ventilation, length of intensive care unit (ICU) stay and mortality were recorded. This study included 45 cases and 22 developed VAP (48%). The incidence of VAP was 25.34 per 1000 ventilator days. Univariate analyses showed that duration of mechanical ventilation, length of ICU stay, coma and tracheotomy were associated with the development of VAP. The mortality rate of cases with VAP (72.7%) was significantly higher than cases without VAP (39.1%). The most frequent microorganisms were Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella pneumoniae. In our study, VAP was a very common and important complication of mechanical ventilation and mortality was very high. To reduce mortality, minimize morbidity, shorten the length of stay, and reduce costs, defined risk factors for VAP should be recognized and an effective infection control program for the prevention of VAP should be implemented. Surveillance results should be evaluated regularly and necessary precautions should be taken.

Epidemiological characteristics of ventilator-associated pneumonia in neurosurgery:A 10-year surveillance study in a Chinese tertiary hospital

Background Ventilator-associated pneumonia(VAP)is a significant and common health concern.The epidemiological landscape of VAP is poorly understood in neurosurgery patients.This study aimed to explore the epidemiology of VAP in this population and devise targeted surveillance,treatment,and control efforts.Methods A 10-year retrospective study spanning 2011 to 2020 was performed in a large Chinese tertiary hospital.Surveillance data was collected from neurosurgical patients and analyzed to map the demographic and clinical characteristics of VAP and describe the distribution and antimicrobial resistance profile of leading pathogens.Risk factors associated with the presence of VAP were explored using boosted regression tree(BRT)models.Results Three hundred ten VAP patients were identified.The 10-year incidence of VAP was 16.21 per 1000 ventilation days.All-cause mortality was 6.1%.The prevalence of gram-negative bacteria,fungi,and gram-positive bacteria among the 357 organisms isolated from VAP patients was 86.0%,7.6%,and 6.4%,respectively;most were multidrug-resistant organisms.Acinetobacter baumannii,Klebsiella pneumoniae,and Pseudomonas aeruginosa were the most common pathogens.The prevalence of carbapenem-resistant A.baumannii,P.aeruginosa,and K.pneumoniae was high and increased over time in the study period.The BRT models revealed that VAP was associated with number of days of ventilator use(relative contribution,47.84±7.25),Glasgow Coma Scale score(relative contribution,24.72±5.67),and tracheotomy(relative contribution,21.50±2.69).Conclusions Our findings provide a better understanding of the epidemiology of VAP and its risk factors in neurosurgery patients.

Early versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation

Background Tracheostomy should be considered to replace endotracheal intubation in patients requiring prolonged mechanical ventilation （MV）. However, the optimal timing for tracheostomy is still a topic of debate. The present study aimed to investigate whether early percutaneous dilational tracheostomy （PDT） can reduce duration of MV, and to further verify whether early PDT can reduce sedative use, shorten intensive care unit （ICU） stay, decrease the incidence of ventilator associated pneumonia （VAP）, and increase successful weaning and ICU discharge rate. Methods A prospective, randomized controlled trial was carried out in a surgical ICU from July 2008 to June 2011 in adult patients anticipated requiring prolonged MV via endotracheal intubation. Patients meeting the inclusion criteria were randomly assigned to the early PDT group or the late PDT group on day 3 of MV. The patients in the early PDT group were tracheostomized with PDT on day 3 of MV. The patients in the late PDT group were tracheostomized with PDT on day 15 of MV if they still needed MV. The primary endpoint was ventilator-free days at day 28 after randomization. The secondary endpoints were sedation-free days, ICU-free days, successful weaning and ICU discharge rate, and incidence of VAP at day 28 after randomization. The cumulative 60-day incidence of death after randomization was also analyzed. Results Total 119 patients were randomized to either the early PDT group （n=58） or the late PDT group （n=61）. The ventilator-free days was significantly increased in the early PDT group than in the late PDT group （（9.57±5.64） vs. （7.38±6.17） days, P 〈0.05）. The sedation-free days and ICU-free days were also significantly increased in the early PDT group than in the late PDT group （20.84±2.35 vs. 17.05±2.30 days, P 〈0.05; and 8.0 （interquartile range （IQR）： 5.0-12.0） vs. 3.0 （IQR： 0-12.0） days, P 〈0.001 respectively）. The successful weaning and ICU discharge rate was significantly higher in early PDT group than in late PDT group （74.1% vs. 55.7%, P 〈0.05; and 67.2% vs. 47.5%, P 〈0.05 respectively）. VAP was observed in 17 patients （29.3%） in early PDT group and in 30 patients （49.2%） in late PDT group （P 〈0.05）. There was no significant difference between the two groups in the cumulative 60-day incidence of death after randomization （P=0.949）. Conclusions The early PDT resulted in more ventilator-free, sedation-free, and ICU-free days, higher successful weaning and ICU discharge rate, and lower incidence of VAP, but did not change the cumulative 60-day incidence of death in the patients＇ anticipated requiring prolonged mechanical ventilation.

Factors associated with low adherence to head-of-bed elevation during mechanical ventilation in Chinese intensive care units

Background Elevating the head of bed （HOB） 30°-45° has been widely supported as a means of ventilator associated pneumonia （VAP） prevention. However, it was poorly adhered in clinical practice. This observational study aimed to investigate the factors impeding this simple practice at the bedside. Methods This prospective study was conducted in 33 Chinese academic hospital intensive care units （ICUs）. HOB angle was measured four times daily at 5-7 hour intervals. The predefined HOB elevation goal was an angle ≥30°. Results The overall rate of achieving the HOB goal was 27.8% of the 8647 measurements in 314 patients during 2842 ventilation days. The HOB goal of ≥3 times/d was consistently achieved only in 15.9% of the cases. Almost 60% of patients had at least one 24 hours period during which the HOB goal was never documented. This low rate of protocol compliance was not associated with acute physiology and chronic health evaluation （APACHE） II score or dependence on vasopressors. In a survey, ＂nurse workload＂ was identified as the most important factor for non-compliance with the HOB goal. In addition, the rates of compliance were significantly different （P 〈0.001） between physicians self-reporting that they either did or did not know the Institutes of Healthcare Improvement （IHI） ventilator bundle. Conclusions Low adherence to a HOB angle of ≥30° was found in this nationwide survey. Nursing workload and lack of knowledge on VAP prevention were important barriers to changin.q this practice.