Top

Published in:

01-11-2017 | Original

Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: a multicenter cluster-randomized cross-over controlled trial

Authors: Emmanuelle Jaillette, Christophe Girault, Guillaume Brunin, Farid Zerimech, Hélène Behal, Arnaud Chiche, Céline Broucqsault-Dedrie, Cyril Fayolle, Franck Minacori, Isabelle Alves, Stéphanie Barrailler, Julien Labreuche, Laurent Robriquet, Fabienne Tamion, Emmanuel Delaporte, Damien Thellier, Claire Delcourte, Alain Duhamel, Saad Nseir, BestCuff Study Group and the BoRéal Network

Published in: Intensive Care Medicine | Issue 11/2017

Abstract

Purpose

Studies on the impact of tapered-cuff tracheal tubes on rates of microaspiration and ventilator-associated pneumonia (VAP) in intubated patients have reported conflicting results. The aim of this study was to determine the influence of this shape of tracheal cuff on abundant microaspiration of gastric contents in critically ill patients.

Methods

All patients intubated in the intensive care unit (ICU) and requiring mechanical ventilation for at least 48 h were eligible for this multicenter cluster-randomized controlled cross-over open-label study. The primary outcome was abundant microaspiration of gastric contents, defined by the presence of pepsin at significant level in >30% of tracheal aspirates. Quantitative measurement of pepsin and salivary amylase was performed in all tracheal aspirates during the 48 h following enrollment.

Results

A total of 326 patients were enrolled in the ten participating ICUs (162 in the PVC tapered-cuff group and 164 in the standard-cuff group). Patient characteristics were similar in the two study groups. The proportion of patients with abundant microaspiration of gastric contents was 53.5% in the tapered-cuff and 51.0% in the standard-cuff group (odds ratio 1.14, 95% CI 0.72–1.82). While abundant microaspiration of oropharyngeal secretions was not significantly different (77.4 vs 68.6%, p = 0.095), the proportion of patients with tracheobronchial colonization was significantly lower (29.6 vs 43.3%, p = 0.01) in the tapered-cuff than in the standard-cuff group. No significant difference between the two groups was found for other secondary outcomes, including ventilator-associated events and VAP.

Conclusions

This trial showed no significant impact of tapered-cuff tracheal tubes on abundant microaspiration of gastric contents.

Trial registration

ClinicalTrials.gov, number NCT01948635.

Available only for authorised users

Nair GB, Niederman MS (2014) Ventilator-associated pneumonia: present understanding and ongoing debates. Intensive Care Med 41:34–48. doi:10.1007/s00134-014-3564-5 CrossRefPubMed

Vincent J-L, Bassetti M, François B et al (2016) Advances in antibiotic therapy in the critically ill. Crit Care 20:133. doi:10.1186/s13054-016-1285-6 CrossRefPubMedPubMedCentral

Melsen WG, Rovers MM, Groenwold RHH et al (2013) Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis 13:665–671. doi:10.1016/S1473-3099(13)70081-1 CrossRefPubMed

Martin-Loeches I, Povoa P, Rodríguez A et al (2015) Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study. Lancet Respir Med 3:859–868. doi:10.1016/S2213-2600(15)00326-4 CrossRefPubMed

Blot SI, Rello J, Koulenti D (2016) The value of polyurethane-cuffed endotracheal tubes to reduce microaspiration and intubation-related pneumonia: a systematic review of laboratory and clinical studies. Crit Care 20:203. doi:10.1186/s13054-016-1380-8 CrossRefPubMedPubMedCentral

Guillamet CV, Kollef MH (2015) Ventilator associated pneumonia in the ICU: where has it gone? Curr Opin Pulm Med 21:226–231. doi:10.1097/MCP.0000000000000151 CrossRefPubMed

Papazian L, Corley A, Hess D et al (2016) Use of high-flow nasal cannula oxygenation in ICU adults: a narrative review. Intensive Care Med. doi:10.1007/s00134-016-4277-8

Kalil AC, Metersky ML, Klompas M et al (2016) Executive summary: management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 63:575–582. doi:10.1093/cid/ciw504 CrossRefPubMedPubMedCentral

Nseir S, Zerimech F, Jaillette E et al (2011) Microaspiration in intubated critically ill patients: diagnosis and prevention. Infect Disord Drug Targets 11:413–423CrossRefPubMed

10.

Blot SI, Poelaert J, Kollef M (2014) How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients. BMC Infect Dis 14:119. doi:10.1186/1471-2334-14-119 CrossRefPubMedPubMedCentral

11.

Lacherade J-C, De Jonghe B, Guezennec P et al (2010) Intermittent subglottic secretion drainage and ventilator-associated pneumonia: a multicenter trial. Am J Respir Crit Care Med 182:910–917. doi:10.1164/rccm.200906-0838OC CrossRefPubMed

12.

Jaillette E, Martin-Loeches I, Artigas A, Nseir S (2014) Optimal care and design of the tracheal cuff in the critically ill patient. Ann Intensive Care 4:7. doi:10.1186/2110-5820-4-7 CrossRefPubMedPubMedCentral

13.

Branson RD, Hess DR (2015) Lost in translation: failure of tracheal tube modifications to impact ventilator-associated pneumonia. Am J Respir Crit Care Med 191:606–608. doi:10.1164/rccm.201502-0206ED CrossRefPubMed

14.

Dave MH, Frotzler A, Spielmann N et al (2010) Effect of tracheal tube cuff shape on fluid leakage across the cuff: an in vitro study. Br J Anaesth 105:538–543. doi:10.1093/bja/aeq202 CrossRefPubMed

15.

Madjdpour C, Mauch J, Dave MH et al (2012) Comparison of air-sealing characteristics of tapered- vs. cylindrical-shaped high-volume, low-pressure tube cuffs. Acta Anaesthesiol Scand 56:230–235. doi:10.1111/j.1399-6576.2011.02542.x CrossRefPubMed

16.

Lichtenthal P, Borg U, Maul D (2010) Do endotracheal tubes prevent microaspiration? Crit Care 14:P229. doi:10.1186/cc8461 CrossRefPubMedCentral

17.

Li Bassi G, Ranzani OT, Marti JD et al (2013) An in vitro study to assess determinant features associated with fluid sealing in the design of endotracheal tube cuffs and exerted tracheal pressures. Crit Care Med 41:518–526. doi:10.1097/CCM.0b013e31826a4804 CrossRefPubMed

18.

Li Bassi G, Luque N, Martí JD et al (2015) Endotracheal tubes for critically ill patients. Chest 147:1327–1335. doi:10.1378/chest.14-1438 CrossRefPubMed

19.

Nseir S, Zerimech F, De Jonckheere J et al (2010) Impact of polyurethane on variations in tracheal cuff pressure in critically ill patients: a prospective observational study. Intensive Care Med 36:1156–1163. doi:10.1007/s00134-010-1892-7 CrossRefPubMed

20.

D’Haese J, De Keukeleire T, Remory I et al (2013) Assessment of intraoperative microaspiration: does a modified cuff shape improve sealing? Acta Anaesthesiol Scand 57:873–880. doi:10.1111/aas.12119 CrossRefPubMed

21.

Monsel A, Lu Q, Le Corre M et al (2016) Tapered-cuff endotracheal tube does not prevent early postoperative pneumonia compared with spherical-cuff endotracheal tube after major vascular surgery: a randomized controlled trial. Anesthesiology. doi:10.1097/ALN.0000000000001053

22.

Philippart F, Gaudry S, Quinquis L et al (2015) Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients. Am J Respir Crit Care Med 191:637–645. doi:10.1164/rccm.201408-1398OC CrossRefPubMed

23.

Bowton DL, Hite RD, Martin RS, Sherertz R (2013) The impact of hospital-wide use of a tapered-cuff endotracheal tube on the incidence of ventilator-associated pneumonia. Respir Care 58:1582–1587. doi:10.4187/respcare.02278 CrossRefPubMed

24.

Jaillette E, Zerimech F, De Jonckheere J et al (2013) Efficiency of a pneumatic device in controlling cuff pressure of polyurethane-cuffed tracheal tubes: a randomized controlled study. BMC Anesthesiol 13:50. doi:10.1186/1471-2253-13-50 CrossRefPubMedPubMedCentral

25.

Jaillette E, Brunin G, Girault C et al (2015) Impact of tracheal cuff shape on microaspiration of gastric contents in intubated critically ill patients: study protocol for a randomized controlled trial. Trials 16:429. doi:10.1186/s13063-015-0955-z CrossRefPubMedPubMedCentral

26.

Nseir S, Zerimech F, Fournier C et al (2011) Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am J Respir Crit Care Med 184:1041–1047. doi:10.1164/rccm.201104-0630OC CrossRefPubMed

27.

Dewavrin F, Zerimech F, Boyer A et al (2014) Accuracy of alpha amylase in diagnosing microaspiration in intubated critically-ill patients. PLoS One 9:e90851. doi:10.1371/journal.pone.0090851 CrossRefPubMedPubMedCentral

28.

Filloux B, Bedel A, Nseir S et al (2013) Tracheal amylase dosage as a marker for microaspiration: a pilot study. Miner Anestesiol 79:1003–1010

29.

American Thoracic Society, Infectious Diseases Society of America (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171:388–416. doi: 10.1164/rccm.200405-644ST

30.

Klompas M, Khan Y, Kleinman K et al (2011) Multicenter evaluation of a novel surveillance paradigm for complications of mechanical ventilation. PLoS One 6:e18062. doi:10.1371/journal.pone.0018062 CrossRefPubMedPubMedCentral

31.

Boles J-M, Bion J, Connors A et al (2007) Weaning from mechanical ventilation. Eur Respir J 29:1033–1056. doi:10.1183/09031936.00010206 CrossRefPubMed

32.

Lizy C, Swinnen W, Labeau S et al (2014) Cuff pressure of endotracheal tubes after changes in body position in critically ill patients treated with mechanical ventilation. Am J Crit Care 23:e1–e8. doi:10.4037/ajcc2014489 CrossRefPubMed

33.

Chenelle CT, Oto J, Sulemanji D et al (2015) Evaluation of an automated endotracheal tube cuff controller during simulated mechanical ventilation. Respir Care 60:183–190. doi:10.4187/respcare.03387 CrossRefPubMed

34.

Paling FP, Wolkewitz M, Bode LGM et al (2016) Staphylococcus aureus colonization at ICU admission as a risk factor for developing S. aureus ICU pneumonia. Clin Microbiol Infect 23(1):49.e9–49.e14. doi:10.1016/j.cmi.2016.09.022 CrossRef

35.

Nseir S, Povoa P, Salluh J et al (2016) Is there a continuum between ventilator-associated tracheobronchitis and ventilator-associated pneumonia? Intensive Care Med. doi:10.1007/s00134-016-4283-x

36.

Mao Z, Gao L, Wang G et al (2016) Subglottic secretion suction for preventing ventilator-associated pneumonia: an updated meta-analysis and trial sequential analysis. Crit Care 20:353. doi:10.1186/s13054-016-1527-7 CrossRefPubMedPubMedCentral

37.

Nseir S, Lorente L, Ferrer M et al (2015) Continuous control of tracheal cuff pressure for VAP prevention: a collaborative meta-analysis of individual participant data. Ann Intensive Care 5:43. doi:10.1186/s13613-015-0087-3 CrossRefPubMedPubMedCentral

38.

Klompas M, Branson R, Eichenwald EC et al (2014) Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 35:915–936. doi:10.1086/677144 CrossRefPubMed

39.

Magill SS, Li Q, Gross C et al (2016) Incidence and characteristics of ventilator-associated events reported to the National Healthcare Safety Network in 2014. Crit Care Med 44:2154–2162. doi:10.1097/CCM.0000000000001871 CrossRefPubMedPubMedCentral

Title: Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: a multicenter cluster-randomized cross-over controlled trial
Authors: Emmanuelle Jaillette
Christophe Girault
Guillaume Brunin
Farid Zerimech
Hélène Behal
Arnaud Chiche
Céline Broucqsault-Dedrie
Cyril Fayolle
Franck Minacori
Isabelle Alves
Stéphanie Barrailler
Julien Labreuche
Laurent Robriquet
Fabienne Tamion
Emmanuel Delaporte
Damien Thellier
Claire Delcourte
Alain Duhamel
Saad Nseir
BestCuff Study Group and the BoRéal Network
Publication date: 01-11-2017
Publisher: Springer Berlin Heidelberg
Published in: Intensive Care Medicine / Issue 11/2017
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-017-4736-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: a multicenter cluster-randomized cross-over controlled trial

Abstract

Purpose

Methods

Results

Conclusions

Trial registration

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Trial registration

Please log in to get access to this content

Other articles of this Issue 11/2017

Fixed minimum volume resuscitation: Pro

Effect of a multifaceted educational intervention for anti-infectious measures on sepsis mortality: a cluster randomized trial

Risk factors of percutaneous cannulation failure by intensivists for veno-arterial extracorporeal life support for refractory cardiac arrest

Randomized, multicenter trial of lateral Trendelenburg versus semirecumbent body position for the prevention of ventilator-associated pneumonia

Clostridium perfringens related spleen gangrene

Erratum to: Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial