Destrebecq A L, Elia G, Terzoni S, Angelastri G, Brenna G, Ricci C, Spanu P, Umbrello M, Iapichino G
Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italia -
Minerva Anestesiol. 2014 Apr;80(4):410-8. Epub 2013 Nov 26.
Gastric residual volume in ventilated critically ill may complicate gut function. Over the years studies suggested to tolerate progressively higher residuals. The relationship between such volumes and the development of ventilator-associated pneumonia (VAP) is still under debate. No reports deal with the relevant anecdotal finding of air in the stomach. Aim of the present study is to test the role of air in the development of VAPs.
Prospective observational trial in consecutive patients with a predicted length of ICU stay >3 days. The first 8 days of stay were studied. Sedation was targeted to have awake/cooperative patients. Early enteral nutrition was attempted. Gastric content was measured every 4 hours by 60 mL-syringe suction. Upper digestive intolerance (UDI) was defined as >2 consecutive findings of liquid >200 mL, aerophagia was defined as >2 consecutive findings of air >150 mL.
Three hundred sixty-four patients enrolled, 43 developed VAP (11.8%). Patients were sedated with enteral (76% total time), intravenous (6%) or both (28%) drugs. Conscious sedation was achieved in 54% of the observations. 326 patients began enteral nutrition during the first 24 hours (1000 kcal median calorie intake). 10% developed UDI, 15% had aerophagia. No association was found between VAP and UDI (P=0.78), while significant association was found between VAP and aerophagia (OR=2.88, P<0.01). A sensitivity analysis, excluding patients admitted with respiratory infection, confirmed the results.
High volumes of air in the stomach significantly increased the risk of developing VAP, while gastric residual volumes were not associated with the incidence of pneumonia.
机械通气的危重症患者胃残余量可能会使肠道功能复杂化。多年来的研究表明可逐渐耐受更高的残余量。此类胃残余量与呼吸机相关性肺炎（VAP）发生之间的关系仍存在争议。尚无报告涉及胃内空气这一相关的偶发发现。本研究的目的是检验胃内空气在VAP发生中的作用。
对预计入住重症监护病房（ICU）时间>3天的连续患者进行前瞻性观察性试验。研究入住的前8天。镇静目标是使患者清醒/配合。尝试早期肠内营养。每4小时用60 mL注射器抽吸测量胃内容物。上消化道不耐受（UDI）定义为连续>2次发现液体>200 mL，吞气症定义为连续>2次发现空气>150 mL。
共纳入364例患者，43例发生VAP（11.8%）。患者使用肠内药物（占总时间的76%）、静脉药物（6%）或两者联合（28%）进行镇静。54%的观察中实现了清醒镇静。326例患者在最初24小时内开始肠内营养（中位热量摄入1000千卡）。10%发生UDI，15%有吞气症。未发现VAP与UDI之间存在关联（P=0.78），而VAP与吞气症之间存在显著关联（比值比=2.88，P<0.01）。一项排除因呼吸道感染入院患者的敏感性分析证实了该结果。
胃内大量空气显著增加了发生VAP的风险，而胃残余量与肺炎发病率无关。
