Chest
Volume 134, Issue 5, November 2008, Pages 938-946
Journal home page for Chest

Original Research
Pneumonia
Continuous Aspiration of Subglottic Secretions in the Prevention of Ventilator-Associated Pneumonia in the Postoperative Period of Major Heart Surgery

https://doi.org/10.1378/chest.08-0103Get rights and content

Objective

Aspiration of endotracheal secretions is a major step in the prevention of ventilator-associated pneumonia (VAP). We compared conventional and continuous aspiration of subglottic secretions (CASS) procedures in ventilated patients after major heart surgery (MHS).

Materials and methods

Randomized comparison during a 2-year period.

Results

A total of 714 patients were randomized (24 patients were excluded from the study; 359 CASS patients; 331 control subjects). The results for CASS patients and control subjects (per protocol and intention-to-treat analysis) were as follows: VAP incidence, 3.6% vs 5.3% (p = 0.2) and 3.8% vs 5.1%, respectively; incidence density, 17.9 vs 27.6 episodes per 1,000 days of mechanical ventilation (MV) [p = 0.18] and 18.9 vs 28.7 episodes per 1,000 days of MV, respectively; hospital antibiotic use in daily defined doses (DDDs), 1,213 vs 1,932 (p < 0.001) and 1,392 vs 1,932, respectively (p < 0.001). In patients who had received mechanical ventilation for > 48 h, the comparisons of CASS patients and control subjects were as follows: VAP incidence, 26.7% vs 47.5% (p = 0.04), respectively; incidence density, 31.5 vs 51.6 episodes per 1,000 days of MV, respectively (p = 0.03); median length of ICU stay, 7 vs 16.5 days (p = 0.01), respectively; hospital antibiotic use, 1,206 vs 1,877 DDD (p < 0.001), respectively; Clostridium difficile-associated diarrhea, 6.7% vs 12.5% (p = 0.3), respectively; and overall mortality rate, 44.4% vs 52.5% (p = 0.3), respectively. Reintubation increased the risk of VAP (relative risk [RR], 6.07; 95% confidence interval [CI], 2.20 to 16.60; p < 0.001), while CASS was the only significant protective factor (RR, 0.40; 95% CI, 0.16 to 0.99; p = 0.04). No complications related to CASS were observed. The cost of the CASS tube was 9 vs 1.5 € for the conventional tube.

Conclusions

CASS is a safe procedure that reduces the use of antimicrobial agents in the overall population and the incidence of VAP in patients who are at risk. CASS use should be encouraged, at least in patients undergoing MHS.

Section snippets

Hospital Setting and Patients

Our institution is a general reference hospital with 1,750 beds and 64,000 admissions per year. The study population included patients who underwent MHS from May 2004 to July 2006. Patients who gave their informed consent were randomly assigned to receive either conventional respiratory care or CASS. Informed consent was obtained by the anesthesiologist in charge in all cases. Our Ethics Committee approved the study. An infectious diseases physician who was aware of the treatment assignments

Study Population

Overall, 1,101 patients underwent MHS during the study period. Of them, 387 patients were excluded either because they did not give their consent (268 patients) or the consent could not be requested due to the emergent condition of the surgery (119 patients). Accordingly, 714 patients undergoing MHS were randomized immediately before undergoing anesthesia (24 patients were excluded from the study; CASS group, 359 patients; control group, 331 subjects). The exclusions were due to death during

Discussion

We found that using CASS in patients undergoing MHS is a safe procedure that significantly reduces the antibiotic burden. In the population that was at high risk (ie, those persons receiving MV for > 48h), CASS reduced the incidence and incidence density of VAP. It also reduced ICU stay, duration of MV, and antibiotic consumption.

VAP is a very severe disease that is associated with a high degree of mortality, and few of the variables influencing mortality can be modified.30, 31, 32, 33, 34, 35,

References (53)

  • MH Kollef et al.

    The effect of late-onset ventilator-associated pneumonia in determining patient mortality

    Chest

    (1995)
  • AA El Solh et al.

    Nosocomial pneumonia in elderly patients following cardiac surgery

    Respir Med

    (2006)
  • SR Leal-Noval et al.

    Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery

    Chest

    (2001)
  • JE Svenson et al.

    Endotracheal intracuff pressures in the ED and prehospital setting: is there a problem?

    Am J Emerg Med

    (2007)
  • R Sierra et al.

    Prevention and diagnosis of ventilator-associated pneumonia: a survey on current practices in southern Spanish ICUs

    Chest

    (2005)
  • C Dezfulian et al.

    Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis

    Am J Med

    (2005)
  • I Zuschneid et al.

    Trends in ventilator-associated pneumonia rates within the German nosocomial infection surveillance system (KISS)

    Infect Control Hosp Epidemiol

    (2007)
  • P Ramirez et al.

    Prevention measures for ventilator-associated pneumonia: a new focus on the endotracheal tube

    Curr Opin Infect Dis

    (2007)
  • N Safdar et al.

    The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention

    Respir Care

    (2005)
  • MH Kollef

    Prevention of hospital-associated pneumonia and ventilator-associated pneumonia

    Crit Care Med

    (2004)
  • R Greene et al.

    Detection of pooled secretions above endotracheal-tube cuffs: value of plain radiographs in sheep cadavers and patients

    AJR Am J Roentgenol

    (1994)
  • P Mahul et al.

    Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis

    Intensive Care Med

    (1992)
  • A Torres et al.

    Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position

    Ann Intern Med

    (1992)
  • J Valles et al.

    Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia

    Ann Intern Med

    (1995)
  • MA Seraj et al.

    Tracheal soiling with blood during intranasal surgery: comparison of two endotracheal tubes

    Middle East J Anesthesiol

    (1991)
  • L Berra et al.

    Evaluation of continuous aspiration of subglottic secretion in an in vivo study

    Crit Care Med

    (2004)
  • Cited by (0)

    This research was supported in part by Ciber de Enfermedades Respiratorias (CIBERES) and by the Rafael del Pino Foundation.

    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    View full text