Appendix C: Subglottic Suctioning and Subglottic
ETT, Literature Synopsis
Ventilator Associated Pneumonia Prevention Bundle
Continuous or frequent intermittent suctioning of subglottic secretions, via an endotracheal tube (ETT) specially designed with a dorsal lumen to accommodate this, is associated with up to a 50% decreased incidence of aspiration and VAP. Guidelines support the use of subglottic suctioning and drainage for patients dependent on mechanical ventilation.
Most recently in 2011, a systematic review and meta-analysis of 13 randomized trials support the use of subglottic drainage for VAP prevention. The 2011 analysis found a 45% reduction of VAP along with a 1.5 days reduction in length of stay and 1.1 days of ventilation.
2008 -Society for Healthcare Epidemiology of America Guidelines: A guideline of practical recommendations to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts.1
ü Recommends the use of cuffed ETT with in line subglottic suction to prevent aspiration and reduce VAP risk factor.
Articles Cited in GuidelineStudy Type and Author / Results - Details in Annotated Bibliography
Systematic Meta-Analysis
Drainage vs. Standard
(Dezfulian, 2005) 2 / Pro-Analyzed 5 RCT to assess the efficacy of subglottic secretion drainage in preventing VAP. Study showed that subglottic secretion drainagecan reduced the incidence ofVAP by nearly half in patients requiring mechanical ventilation.
CDC Guideline- 20033 / Pro - If feasible, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage (by continuous or frequent intermittent suctioning) of tracheal secretions that accumulate in the patient’s subglottic area. (See CDC Section)
Review
(Kollef, 2004) 4 / Pro-This review did not specifically address subglottic suctioning. However, it recommended the use of endotracheal tube with separate dorsal lumen based on the beneficial effect on lowering VAP incidences.
Continuous vs. Closed Lumen Care
(Valles, 1995) 5 / Pro- Study focused on ICU patients expected to be intubated for >3 days. The study findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continues subglottic suctioning through the dorsal lumen.
* Continuous vs. w/o Suctioning
(Kollef, 1999) 6 / Pro- Study focused on cardiothoracic surgery patients requiring mechanical ventilation. Findings showed that the occurrence of VAP can be significantly delayed with the use of continuous aspiration of subglottic secretion.
Contempo
(Cook, 1998) 7 / Pro- This article did not focus on suctioning, but summarized 12 studies that evaluate risk factors for ICU-acquired pneumonia in critically ill patients. One of the VAP risk factors identified was failed subglottic suctioning.
Drainage vs. Sucralfate
(Mahul, 1992) 8 / Pro- Study focused patients requiring mechanical ventilation for 3 days. Findings showed subglottic drainage was effective at lowering nosocomial pneumonia, but sucralfate prevention was not.
2008-Canadian VAP Prevention Guidelines: Evidence-based, clinical practice guidelines for the prevention of ventilator-associated pneumonia1
ü Subglottic Secretion Drainage is recommended for patients requiring to be mechanically ventilated for more than 72hrs.
ü
Articles Cited in GuidelineStudy Type and Author / Results - Details in Annotated Bibliography
Drainage vs. Conventional Oral ETT
(Smulders, 2002)9 / Pro- Study focused on ICU patients expected to be mechanicalventilated >72 h. Findings showed that intermittent subglottic secretion drainage reduces the rate of VAP in patient receiving mechanical ventilation.
Drainage vs. Control
(Bo, 2000)10 / Pro- Study focused on surgical patients who required intubation. Study showed that the morbidity of VAP can be reduced by using subglottic secretion drainage; especially for gram- positive cocci and Haemophilius influenzae caused VAP cases.
Continuous vs. Closed Lumen Care
(Valles, 1995)5 / Pro- Study focused on medical and surgical patients requiring prolonged intubation (> 3 days). Findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continues subglottic suctioning.
(Previously cited by SHEA)
Drainage vs. Sucralfate
(Mahul, 1992)8 / Pro- Study focused on patients who required mechanical ventilation for 3 days. Findings showed that subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not.
(Previously cited by SHEA )
2004-Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. 11
ü Recommends the use of specifically designed ETT with dorsal lumen for the continues aspiration of subglottic secretion.
Articles Cited in GuidelineStudy Type and Author / Results - Details in Annotated Bibliography
Continuous vs. w/o Suctioning
(Kollef, 1999) 6 / Pro- Study focused on cardiothoracic surgery patients requiring mechanical ventilation. Findings showed that VAP occurrence can be significantly delayed with the use of continuous aspiration of subglottic secretion.
(Previously cited by SHEA )
Continuous vs. Closed Lumen Care
(Valles, 1995) 5 / Pro- Study focused on patients requiring prolonged intubation (> 3 days) in the medical – surgical ICU. Findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continues suctioning. (Previously cited by SHEA and ZAP)
Drainage vs. Sucralfate
(Mahul, 1992) 8 / Pro- Study focused on patients who required mechanically ventilated for more than 3 days. Study showed that the prevention of micro-aspiration with the use of subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not.
(Previously cited by SHEA and ZAP)
2
2003- CDC Guidelines for preventing Health-Care-Associated Pneumonia; Evidence-based, clinical practice guidelines for the prevention of healthcare-associated pneumonia, including VAP. 3
ü Recommends the use of an ETT dorsal lumen above the endotracheal cuff to allow drainage by continuous or frequent intermittent suctioning of tracheal secretion that accumulates in patient’s subglottic area.
Articles Cited in GuidelineStudy Type and Author / Results - Details in Annotated Bibliography
Intermittent Drainage vs. Standard ETT
(Smulders, 2002) 9 / Pro- Study focused on ICU patients expected to be mechanicalventilated >72 h .Findings showed that intermittent subglottic secretion drainage reduces the rate of VAP in patient receiving mechanical ventilation.
Continuous vs. w/o Suctioning
(Kollef, 1999) 6 / Pro- Study focused on cardiothoracic c surgery patients requiring mechanical ventilation. Findings showed that the occurrence of VAP can be significantly delayed with the use of continuous aspiration of subglottic secretion. (Previously cited by SHEA and ATS)
Contempo
(Cook, 1998)7 / Pro- This article did not focus on suctioning, but summarized 12 studies that evaluate risk factors for ICU-acquired pneumonia in critically ill patients. One of the VAP risk factors identified was failed subglottic suctioning. (Previously cited by SHEA)
Continuous vs. Closed Lumen ETT
(Valles, 1995) 5 / Pro- Study focused on patients requiring prolonged intubation (> 3 days) in the medical – surgical intensive care unit. Findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continues suctioning. (Previously cited by SHEA, ZAP and ATS}
Drainage vs. Sucralfate
(Mahul, 1992) 8 / Pro- Study focused on patients who required mechanically ventilated patient for more than 3 days. Study findings conclude that the prevention of micro-aspiration with the use of subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not. (Previously cited by SHEA, ATS, and ZAP)
Post Guideline Publications:
Post Guideline Publications, 2007-2012Study Type and Author / Results - Details in Annotated Bibliography
Systematic Review and Meta-Analysis
(Leasure, 2012)12 / Pro- Study reviewed 12 original articles and 4 reviews that evaluated the effectiveness of subglottic secretion drainage (SDD) in reducing the occurrence of VAP. The findings of review support the recommendation for use of ETTs with SSD based on a 52% reduction rate.
Systematic Review and Meta-Analysis
(Muscedere, 2011) 13 / Pro- Study focused on 13 RCTs evaluating subglottic secretion drainage in adult mechanically ventilated patients. Study findings support the use of subglottic endotracheal tube in reduction rate of VAP.
Intermittent Drainage vs. Closed Suctioning System
(Juneja, 2011) 14 / Pro - Study focused on patients requiring mechanical ventilation for more than 72 hours. Study findings conclude that intermittent subglottic drainage reduces the incidence of VAP.
Cost Benefit Analysis
Conventional Tubes vs. Continuous Subglottic Suctioning Tubes
(Hallais, 2011) 15 / Pro- Study in France analyzed the cost benefit of 416 surgical ICU patients receiving mechanical ventilation for 3,487 ventilation days. Finding showed replacing conventional ventilator tubes with continuous subglottic suctioning tubes were cost the cost averted per VAP episode is €1,383.69.
Business Case
Continues ETT vs. Standard ETT
(Speroni ,2011) 16 / Pro- Study was focused on medical and surgical ICU patients who were expected to be ventilated for >48 hrs. Study findings recommend the use of Continues -ETT over Standard S-ETT based on the final attributable cost of VAP.
Systematic Review
(Overend, 2009) 17 / Pro-Analyzed 15 RCT and 13 RCO of mechanically ventilated adult patients. Study showed that new evidence continues to be varied in strength for suctioning practice, but the evidence has improved since 2001 suggesting that members of the health care team should incorporate this evidence into their practice.
Literature Review
(Depew, 2007) 18 / Pro- Review of meta-analysis 2 that looked at 5RCT that compared aspiration of subglottic secretion vs. standard ETT care. Findings conclude that there insufficient outcome evidence to support the use of subglottic technology – aside from the VAP rate reduction.
4
Annotated Bibliography
1. Coffin S, MD, Klompas M, MD, Classen D, MD, et al. Strategies to prevent Ventilator‐Associated pneumonia in acute care hospitals. Infection Control and Hospital Epidemiology. 2008;29(S1, A Compendium of Strategies to Prevent Healthcare‐Associated Infections in Acute Care Hospitals):pp. S31-S40. Available from: http://www.jstor.org/stable/10.1086/591062.
2. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia:A meta-analysis. American Journal of Medicine. 2005;11-18(118).
Pro- Meta Analysis – Drainage vs. Standard Endtracheal Treatment - Study evaluated 896 patients from 5 RCT who required mechanical ventilation. Subglottic secretion drainage reduced the incidence of ventilator-associated pneumonia by nearly half (risk ratio [RR] = 0.51; 95% confidence interval [CI]: 0.37 to 0.71), primarily by reducing early-on set pneumonia (pneumonia occurring within 5 to 7 days after intubation). Subglottic secretion drainage appears effective in preventing early-onset ventilator-associated pneumonia among patients expected to require >72 hours of mechanical ventilation.
3. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidleines for preventing healthcare-associated pneumonia, 2003: Recommendations of CDC and the healthcare infection control practices advisory committee. MMWR Recomm Rep. 2004;53:1-36.
4. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med. 2004;32(6):1396-1405.
Pro- Review - Synthesized the available clinical data for the prevention of hospital-associated pneumonia (HAP) and ventilator- associated pneumonia (VAP) This review did not specifically address subglottic suctioning, but recommends the use of endotracheal tube with separate dorsal lumen based on 4 papers that showed beneficial effect.
5. Valles J, Artigas A, Rello J, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Annals of Internal Medicine. 1995(122):179–186.
Pro- Continuous vs. Closed Lumen ETT - Study focused on 190 ICU patients expected to be intubated for >3 days. The incidence rate of VAP was 19.9 episodes/1000 ventilator days in the patients receiving continuous aspiration of subglottic secretions and 39.6 episodes/1000 ventilator days in the control patients (closed lumen ETT) (relative risk, 1.98; 95% CI, 1.03 to 3.82). Episodes of ventilator-associated pneumonia developed later in patients receiving continuous aspiration (12.0 ± 7.1 days) than in the control patients (5.9 ± 2.1 days) (P < 0.001).This difference was due to a significant (P< 0.03) reduction in the number of gram-positive cocci and Haemophilus influenzaeorganisms in the patients receiving continuous aspiration.
6. Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest. 1999;116(5):1339-1346.
Pro- Continuous vs. w/o Suctioning - Study focused on 371 cardiac surgery patient requiring mechanical ventilation in the Cardiothoracic ICU. VAP was seen in 8 patients (5.0%) receiving continues suctioning and in 15 patients (8.2%) receiving routine postoperative medical care without suctioning (relative risk, 0.61%; 95% confidence interval, 0.27 to 1.40; p = 0.238). Episodes of VAP occurred statistically later among patients receiving continuous suctioning ([mean ± SD] 5.6 ± 2.3 days) than among patients who did not receive suctioning (2.9 ± 1.2 days); (p = 0.006). No statistically significant differences for hospital mortality, overall duration of mechanical ventilation, lengths of stay in the hospital or CTICU, or acquired organ system derangements were found between the two treatment groups. The occurrence of VAP can be significantly delayed among patients undergoing cardiac surgery using this simple-to-apply technique of continuous suctioning.
7. Cook DJ, Kollef MH. Risk factors for ICU-acquired pneumonia. JAMA. 1998;279(20):1605-1606.
Pro- This review did not focus on subglottic suctioning intervention, but summarizes 12 studies that evaluate risk factors for ICU-acquired pneumonia in critically ill patients. One of the VAP risk factors identified was failed subglottic suctioning.
8. Mahul P, Auboyer C, Jospe R, et al. Prevention of nosocomial pneumonia in intubated patients: Respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Medecine. 1992(18):20-25.
Pro- Drainage vs. Sucralfate - Study focused 145 patients who required mechanically ventilated for > 3 days. Subglottic secretion drainage (SSD) treatment was associated with: a) a twice lower incidence of nosocomial pneumonia (NP) (no-SSD: 29.1%, SSD: 13%); b) a prolonged time of onset of NP (no-SSD: 8.3±5 days, SSD: 16.2±11 days); c) a decrease in the colonization rate from admission to end-point day in tracheal aspirates (no-SSD:+21.3%, SSD:+6.6%) and in subglottic secretions (no-SSD:+33.4%, SSD:+2.1%). Study findings conclude that the prevention of micro-aspiration with the use of subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not.