Bouza Emilio, Pérez María Jesús, Muñoz Patricia, Rincón Cristina, Barrio José María, Hortal Javier
Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain.
Department of Anesthesiology, Ciber de Enfermedades Respiratorias (CIBERES), Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain.
Chest. 2008 Nov;134(5):938-946. doi: 10.1378/chest.08-0103. Epub 2008 Jul 18.
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).
Randomized comparison during a 2-year period.
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 euro for the conventional tube.
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.
气管内吸痰是预防呼吸机相关性肺炎（VAP）的重要步骤。我们比较了心脏大手术后（MHS）通气患者的传统声门下分泌物吸引法与持续声门下分泌物吸引法（CASS）。
在2年期间进行随机对照研究。
共714例患者被随机分组（24例患者被排除在研究之外；359例采用CASS的患者；331例对照受试者）。采用CASS的患者和对照受试者的结果（符合方案分析和意向性分析）如下：VAP发生率分别为3.6%和5.3%（p = 0.2），以及3.8%和5.1%；发病密度分别为每1000天机械通气（MV）17.9次和27.6次（p = 0.18），以及每1000天MV 18.9次和28.7次；每日限定剂量（DDD）的医院抗生素使用量分别为1213和1932（p < 0.001），以及1392和1932（p < 0.001）。在接受机械通气超过48小时的患者中，采用CASS的患者和对照受试者的比较结果如下：VAP发生率分别为26.7%和47.5%（p = 0.04）；发病密度分别为每1000天MV 31.5次和51.6次（p = 0.03）；ICU住院时间中位数分别为7天和16.5天（p = 0.01）；医院抗生素使用量分别为1206和1877 DDD（p < 0.001）；艰难梭菌相关性腹泻发生率分别为6.7%和12.5%（p = 0.3）；总体死亡率分别为44.4%和52.5%（p = 0.3）。再次插管增加了VAP的风险（相对风险[RR]，6.07；95%置信区间[CI]，2.20至16.60；p < 0.001），而CASS是唯一显著的保护因素（RR，0.40；95%CI，0.16至0.99；p = 0.04）。未观察到与CASS相关的并发症。CASS管的成本为9欧元，而传统管为1.5欧元。
CASS是一种安全的方法，可减少总体人群中抗菌药物的使用以及有风险患者的VAP发生率。应鼓励使用CASS，至少在接受MHS的患者中。
