Michelson A, Kamp H D, Schuster B
Klinik und Poliklinik für Hals-Nasen-Ohrenkranke, Universität Erlangen-Nürnberg.
Anaesthesist. 1991 Feb;40(2):100-4.
Discussion of paranasal sinusitis as a nosocomial infection in the mechanically ventilated intensive care (ICU) patient has recently been intensified. Some authors have emphasized nasotracheal intubation as a possible pathogenetic pathway. The aim of this study was to investigate the impact of nasotracheal or orotracheal intubation on the development of sinusitis in ICU patients.
In a prospective study, we followed 44 patients who required mechanical ventilation (greater than 24 h) in the ICU because of prolonged recovery from abdominal, thoracic, or posttraumatic surgery. Twenty patients were intubated nasotracheally and 24 orotracheally. Assignment to the groups was random. All were provided with a nasogastric tube and initially treated with systemic antibiotics. They received local antimicrobial prophylaxis of the nose, oropharynx, and stomach. Daily a-scan examinations of the maxillary sinuses were performed from the day of admission to the ICU until extubation, tracheotomy, death, or transfer. The average observation period was 6.9 days in the oral group and 7.1 days in the nasal group. In the case of a pathologic finding, aspiration of the antral sinus was carried out. In this study sinusitis indicated a sonographic finding; it did not necessarily imply a bacterial infection.
At the beginning of the observation period, 6 patients in the oral group and 4 in the nasal group already had a pathologic maxillary sinus finding. At the end, in 15 of 24 in the oral group and 19 of 20 in the nasal group unilateral or bilateral sinusitis could be demonstrated. Development of bilateral sinusitis (13/20 in the nasotracheal group, 8/24 in the orotracheal group) was mainly observed after the appearance of unilateral sinusitis. The site corresponded to the site of the nasal tube in 65%. Unilateral paranasal infection was observed in nasotracheally and orotracheally intubated patients after an average of 2.8 and 2.6 days, respectively, whereas bilateral sinusitis had an average time delay of 4.5 and 5.7 days. Aspiration of the maxillary sinus was performed in 22 of 34 cases with sinusitis. Pathogenic organisms could be demonstrated in 7 of 13 nasotracheally intubated patients but only 2 of 9 with orotracheal tubes.
We found that patients intubated orotracheally developed significantly less sinusitis than those intubated nasotracheally. Edema, local infection of the nasal mucosa, or mechanical obstruction of sinus drainage pathways by the tube are possible explanations. The fact that 63% of orally intubated patients had a pathologic maxillary sinus finding as well suggests that in addition to other reasons, an increased central venous pressure, positive pressure ventilation, and the supine position must be regarded as predisposing factors that increase the incidence of sinusitis. We conclude that the conditions of critically ill patients predispose to the development of sinusitis. Nasotracheal intubation is to be regarded as an additional risk, and therefore oral intubation should be preferred.
关于鼻窦炎作为机械通气重症监护病房（ICU）患者医院感染的讨论近来愈发激烈。一些作者强调经鼻气管插管是一条可能的发病途径。本研究的目的是调查经鼻气管插管或经口气管插管对ICU患者鼻窦炎发生的影响。
在一项前瞻性研究中，我们对44例因腹部、胸部或创伤后手术恢复时间延长而在ICU需要机械通气（超过24小时）的患者进行了跟踪。20例患者经鼻气管插管，24例经口气管插管。分组是随机的。所有患者均留置鼻胃管并最初接受全身抗生素治疗。他们接受了鼻腔、口咽部和胃部的局部抗菌预防。从入住ICU当天直至拔管、气管切开、死亡或转院，每天对上颌窦进行A超检查。经口组的平均观察期为6.9天，经鼻组为7.1天。如果发现病理改变，则对上颌窦进行抽吸。在本研究中，鼻窦炎指超声检查发现的情况；不一定意味着细菌感染。
在观察期开始时，经口组有6例患者、经鼻组有4例患者已经有上颌窦病理改变。在观察期结束时，经口组24例中有15例、经鼻组20例中有19例可证实有单侧或双侧鼻窦炎。双侧鼻窦炎（经鼻气管插管组20例中有13例，经口气管插管组24例中有8例）主要在单侧鼻窦炎出现后观察到。65%的情况中病变部位与鼻胃管位置相对应。经鼻气管插管和经口气管插管患者分别平均在2.8天和2.6天后出现单侧鼻旁窦感染，而双侧鼻窦炎平均延迟时间分别为4.5天和5.7天。34例鼻窦炎患者中有22例进行了上颌窦抽吸。经鼻气管插管的13例患者中有7例可证实有致病微生物，但经口气管插管的9例中只有2例。
我们发现经口气管插管的患者发生鼻窦炎的情况明显少于经鼻气管插管的患者。水肿、鼻黏膜局部感染或鼻胃管对鼻窦引流途径的机械性阻塞可能是原因。63%经口气管插管患者也有上颌窦病理改变这一事实也表明，除其他原因外，中心静脉压升高、正压通气和仰卧位必须被视为增加鼻窦炎发生率的易感因素。我们得出结论，重症患者的状况易引发鼻窦炎。经鼻气管插管应被视为一个额外风险，因此应优先选择经口插管。
