Médecine Intensive Réanimation, CHU Lille, F-59000, Lille, France.
Faculté de Médicine, Université de Lille, F-59000, Lille, France.
Crit Care. 2019 Apr 5;23(1):111. doi: 10.1186/s13054-019-2403-z.
Microaspiration of gastric and oropharyngeal secretions is the main mechanism of entry of bacteria into the lower respiratory tract in intubated critically ill patients. The aim of this study is to determine the impact of enteral nutrition, as compared with parenteral nutrition, on abundant microaspiration of gastric contents and oropharyngeal secretions.
Planned ancillary study of the randomized controlled multicenter NUTRIREA2 trial. Patients with shock receiving invasive mechanical ventilation were randomized to receive early enteral or parenteral nutrition. All tracheal aspirates were collected during the 48 h following randomization. Abundant microaspiration of gastric contents and oropharyngeal secretions was defined as the presence of significant levels of pepsin (> 200 ng/ml) and salivary amylase (> 1685 UI/ml) in > 30% of tracheal aspirates.
A total of 151 patients were included (78 and 73 patients in enteral and parenteral nutrition groups, respectively), and 1074 tracheal aspirates were quantitatively analyzed for pepsin and amylase. Although vomiting rate was significantly higher (31% vs 15%, p = 0.016), constipation rate was significantly lower (6% vs 21%, p = 0.010) in patients with enteral than in patients with parenteral nutrition. No significant difference was found regarding other patient characteristics. The percentage of patients with abundant microaspiration of gastric contents was significantly lower in enteral than in parenteral nutrition groups (14% vs 36%, p = 0.004; unadjusted OR 0.80 (95% CI 0.69, 0.93), adjusted OR 0.79 (0.76, 0.94)). The percentage of patients with abundant microaspiration of oropharyngeal secretions was significantly higher in enteral than in parenteral nutrition groups (74% vs 54%, p = 0.026; unadjusted OR 1.21 (95% CI 1.03, 1.44), adjusted OR 1.23 (1.01, 1.48)). No significant difference was found in percentage of patients with ventilator-associated pneumonia between enteral (8%) and parenteral (10%) nutrition groups (HR 0.78 (0.26, 2.28)).
Our results suggest that enteral and parenteral nutrition are associated with high rates of microaspiration, although oropharyngeal microaspiration was more common with enteral nutrition and gastric microaspiration was more common with parenteral nutrition.
ClinicalTrials.gov, NCT03411447 . Registered 18 July 2017. Retrospectively registered.
胃和口咽分泌物的微吸入是机械通气危重症患者下呼吸道细菌进入的主要机制。本研究旨在确定与肠外营养相比，肠内营养对胃内容物和口咽分泌物大量微吸入的影响。
随机对照多中心 NUTRIREA2 试验的计划辅助研究。接受有创机械通气的休克患者被随机分为早期肠内或肠外营养组。在随机分组后 48 小时内收集所有气管抽吸物。大量胃内容物和口咽分泌物微吸入定义为气管抽吸物中存在大量胃蛋白酶（>200ng/ml）和唾液淀粉酶（>1685UI/ml），超过 30%的抽吸物。
共纳入 151 例患者（肠内和肠外营养组分别为 78 例和 73 例），对 1074 份气管抽吸物进行了胃蛋白酶和淀粉酶的定量分析。尽管肠内营养组呕吐发生率明显高于肠外营养组（31% vs 15%，p=0.016），但肠内营养组便秘发生率明显低于肠外营养组（6% vs 21%，p=0.010）。两组患者的其他特征无显著差异。肠内营养组胃内容物大量微吸入的患者比例明显低于肠外营养组（14% vs 36%，p=0.004；未校正 OR 0.80（95%CI 0.69,0.93），校正 OR 0.79（0.76,0.94））。肠内营养组口咽分泌物大量微吸入的患者比例明显高于肠外营养组（74% vs 54%，p=0.026；未校正 OR 1.21（95%CI 1.03,1.44），校正 OR 1.23（1.01,1.48））。肠内（8%）和肠外（10%）营养组之间呼吸机相关性肺炎患者的比例无显著差异（HR 0.78（0.26,2.28））。
我们的结果表明，肠内和肠外营养均与高微吸入率相关，尽管肠内营养时口咽微吸入更为常见，而肠外营养时胃微吸入更为常见。
ClinicalTrials.gov，NCT03411447。2017 年 7 月 18 日注册。回顾性注册。
