Armamentarium to prevent VAP. Innovations in Endotracheal Tubes. Armamentarium to prevent VAP. Avoiding accumulation of subglottic secretions

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1 Symposium Trends in de Spoedgevallen en Intensive Zorgen Thomas More Hogeschool, Mechelen, 17 mei 2018 Armamentarium to prevent VAP microaspiration Ventilator-Associated Pneumonia Innovations in Endotracheal Tubes Stijn BLOT Dept. of Internal Medicine Faculty of Medicine & Health Science Ghent University, Ghent, Flanders (Belgium) Burns, Trauma and Critical Care Research Centre The University of Queensland, Brisbane, Queensland (Australia) bacterial translocation biofilm formation Modulation of colonization Reduction of exposure time Basic infection control Armamentarium to prevent VAP Avoiding accumulation of subglottic secretions Subglottic secretions drainage microaspiration bacterial translocation biofilm formation Modulation of colonization Reduction of exposure time Basic infection control Subglottic secretions drainage PEEP Automated Pcuff control Ultrathin ETT cuff wall Tapershaped cuff Principle: - suctioning of secretions that accumulate above the cuff - continuously or intermittent Avoiding accumulation of subglottic secretions Subglottic secretions drainage Problem HV-LP cuffs: inflation folds channels Meta-analysis of 13 RCTs - Overall result: RR 0.55 (95% CI ) - 4 high quality RCTs: RR 0.54 (95% CI ) (!) Importance of a dedicated and wellinstructed nursing team PVC cuff PU cuff Cuff wall thickness micron ~10 micron Folds with channel formation Folds without channel formation Muscedere J, et al. Crit Care Med 2011 Dullenkopf A, et al. Intensive Care Med

2 Systematic review o Laboratory o Clinical Outcomes o Leakage/micro aspiration o Intubation related pneumonia In vitro studies o Dullenkopf, Intensive Care Med 2003 o Lucangelo, Crit Care Med 2008 o Dave, Br J Anesth 2010 o Dave, Minerva Anesthesiol 2011 o Kolobow, Respir Care 2011 o Ouanes, Intensive Care Med 2011 o Zanella, Intensive Care Med 2011 o Li Bassi, Crit Care Med 2013 o Lau, Hong Kong Med J 2014 In vivo study o Li Bassi, Chest 2016 (!) Broad heterogeneity in experimental set up o shape and elasticity of the trachea model o positioning if the ETT (vertical or 30 above horizontal) o room T o gel lubrication of the cuff o viscosity of the test fluid o ventilatory simulation ± PEEP (at various levels) ± tracheal suctioning simulation (at various suction pressures) o duration of leakage observation (20 min. 1 hr. 24 hrs.) (!) In all in vitro studies PU cuffs sealed substantially / significantly better compared with PVC cuffs proof of concept! Clinical data: outcome = micro-aspiration Lucangelo (Crit Care Med 2008) o RCT o Bronchoscopic evaluation of presence of Evans blue in trachea at 1, 5 and 12 hrs. post intubation Clinical data: outcome = pneumonia Author, year Design, cohort Poelaert, 2008 RCT, 1 CSICU Early post op. pneumonia Outcome Result P PU: 23% (15/67) PVC: 42% (28/67) 0.03 Nseir (Intensive Care Med 2010) o Prospective observational trial o Pepsin in tracheal secretions as measure for micro aspiration o Recorded at 24 hrs. post intubation significantly less micro aspiration in PU cuffed ETTs Miller, 2011 Suhas, 2016 Philippart, 2015 Before after study; 5 ICUs 1 center RCT, SICU Multicenter RCT, 4 groups VAP Baseline (PVC): 5.3/1000 MVD Intervent. (PU): 2.8/1000 MVD VAP PU: 15% (6/40) PVC: 33% (13/40) VAP PU cylindrical: 17% PVC cylindrical: 11% PU tapered: 16% PVC tapered: 13% Micro-aspiration Early post-op. pneum. Average intubation time <24 hrs Clinical data VAP Average intubation time days Conclusion PU cuffed ETT seems to postpone rather than to avoid microaspiration, and as such clinical benefits are more obvious in short term intubated patients. Pos. effect of PU cuffed ETT No effect of PU cuffed ETT 2

3 Proximal cuff: Cuff diameter > Tracheal diameter Sealing band (mid cuff): Cuff diameter = Tracheal diameter eliminating excess cuff material locally In vitro research: taper shaped cuffs - reduce fluid leakage by an average of 90% - reduce air leakage (!) proof of concept! Mecca R & Torpey H. white paper Covidien 2008 Madjdpour et al. Eur J Anesthesiol 2009 Clinical data: outcome = micro-aspiration Leakage of methyleen blue dye besides the cuff in patients undergoing gastric bypass surgery: Clinical data: intubation-associated respir. tract infection Endoscopy confirmed leakage of methyleen blue besides the cuff Taper-shaped PVC cuff Barrel-shaped PVC cuff 0/33 (0%) 15/34 (44%) Mulier J, et al. Congress of the ASA, San Diego, 2010 D Haese J, et al. Acta Anaest Scand 2013 Gaszynska E, et al. Polski Przeglad Chirurgizny 2014 Maertens B, et al. Crit Care Med 2018 WARNING! (!) No use of automated Pcuff monitoring in the trials assessing value of PU- & tapershape-cuffed ETTs. (!) Clinical value of these cuffs can only be optimally assessed when Pcuff is completely controlled. Conclusion: PU- & Tapershape-cuffed ETT Proof of concept o Reduce leakage (in vitro) o Recuce micro-aspiration No reduction of pneumonia in RCTs o Exception: PU-cuff early post-op. pneumonia Both ETT-designs deserve re-assessment in circumstances with optimal Pcuff control 3

4 WARNING! Target range: cm H 2 O Factors influencing Pcuff Factor Effect on cuff pressure (Pcuff) References Time loss of cuff volume with me Pcuff Sole ML, et al. Crit Care Med 2003 Adequate capillary perfusion in tracheal mucosa (cuff pressure <30 cm H 2 O) Cuff pressure cm H 2 O Adequate sealing of the extra luminal airway (cuff pressure >20 cm H 2 O) Rello J, et al. Am J Respir Crit Care Med 1996 Brimacombe J, et al. Br J Anesth 1999 Positive pressure ventilation pressure ven la on Pcuff Bernhard WN, et al. Chest 1985 Guyton D, et al. Chest 1991 Core temperature (T ) as T Pcuff Inada T, et al. Br J Anesth 1995 N 2 O ventilation diffusion of N 2 O in cuff Pcuff Nguyen T, et al. Anest Analg 1999 Braz JR, et al. Sao Paulo Med J 1999 Sedation and neuromuscular block Bronchoconstriction, laryngeal spasms, edema formation Changes in patient positioning in muscle tone Pcuff in airway pressure or narrowing tracheal diameter Pcuff Mehta, Myat. Ann Royal Coll Surg Engl 1984 Girling KJ, et al. Anesth Analg 1999 Sole ML, et al. Am J Crit Care 2002 migra on of ETT in trachea Pcuff Kim JT, et al. Can J Anesth 2009 Lizy C, et al. Am J Crit Care 2014 Helicopter transport high al tude Pcuff Bassi M, et al. Ann Emerg Med 2010 Lanz tm pressure regulating valve Frequent cuff pressure monitoring is necessary. In practice: generally 1 to 3 times daily. Observational studies: 50 79% of Pcuff outside the target range. Gold standard: pneumatic/automated device for continuous Pcuff monitoring and/or adjustment. Automated devices to regulate Pcuff (external to ETT) Conclusion Baseline for evaluating ETTs for respiratory infection is continuous Pcuff monitoring (and this was not the case for evaluating PU and taper-shaped ETTs) PU-cuffed ETTs: most probably advantageous in short-term intubated patients Taper-shaped ETTs: no proven benefit Subglottic secretion drainage: proven benefit Maertens B, et al. ICMx 2016_abstract annual congress ESICM, Milan 4

5 Thank you Dept. of Internal Medicine, Faculty of Medicine & Health Science, Ghent University Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, Australia 5