Schults Jessica A, Cooke Marie, Long Debbie, Schibler Andreas, Ware Robert S, Charles Karina, Irwin Adam, Mitchell Marion L
Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia; Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Queensland, Australia; Paediatric Critical Care Research Group, Centre for Children's Health Research, The University of Queensland, South Brisbane, Queensland, Australia.
Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Queensland, Australia.
Aust Crit Care. 2021 Nov;34(6):530-538. doi: 10.1016/j.aucc.2021.01.006. Epub 2021 May 26.
BACKGROUND/OBJECTIVE: Endotracheal suction is one of the most common and harmful procuedres performed on mechanically ventilated children. The aim of the study was to establish the feasibility of a randomised controlled trial (RCT) examining the effectiveness of normal saline instillation (NSI) and a positive end-expiratory pressure recruitment manoeuvre (RM) with endotracheal suction in the paediatric intensive care unit.
Pilot 2 × 2 factorial RCT. The study was conducted at a 36-bed tertiary paediatric intensive care unit in Australia. Fifty-eight children aged less than 16 years undergoing tracheal intubation and invasive mechanical ventilation. (i) NSI or no NSI and (ii) RM or no RM with endotracheal suction . The primary outcome was feasibility; secondary outcomes were ventilator-associated pneumonia (VAP), change in end-expiratory lung volume assessed by electrical impedance tomography, dynamic compliance, and oxygen saturation-to-fraction of inspired oxygen (SpO/FiO) ratio.
RESULTS/FINDINGS: Recruitment, retention, and missing data feasibility criteria were achieved. Eligibility and protocol adherence criteria were not achieved, with 818 patients eligible and 58 enrolled; cardiac surgery was the primary reason for exclusion. Approximately 30% of patients had at least one episode of nonadherence. Children who received NSI had a reduced incidence of VAP; however, this did not reach statistical significance (incidence rate ratio = 0.12, 95% confidence interval = 0.01-1.10; p = 0.06). NSI was associated with a significantly reduced SpO/FiO ratio up to 10 min after suction. RMs were not associated with a reduced VAP incidence (incidence rate ratio = 0.31, 95% confidence interval = 0.05-1.88), but did significantly improve end-expiratory lung volume at 2 and 5 min after suction, dynamic compliance, and SpO/FiO ratio.
RMs provided short-term improvements in end-expiratory lung volume and oxygenation. NSI with suction led to a reduced incidence of VAP; however, a definitive RCT is needed to test statistical differences. A RCT of study interventions is worthwhile and may be feasible with protocol modifications including the widening of participant eligibility.
背景/目的：气管内吸痰是对机械通气儿童实施的最常见且有害的操作之一。本研究的目的是确定一项随机对照试验（RCT）的可行性，该试验旨在探讨在儿科重症监护病房中，气管内吸痰时生理盐水滴注（NSI）和呼气末正压复张手法（RM）的有效性。
先导性2×2析因随机对照试验。研究在澳大利亚一家拥有36张床位的三级儿科重症监护病房进行。58名年龄小于16岁且正在接受气管插管和有创机械通气的儿童。（i）吸痰时进行NSI或不进行NSI，以及（ii）吸痰时进行RM或不进行RM。主要结局是可行性；次要结局是呼吸机相关性肺炎（VAP）、通过电阻抗断层扫描评估的呼气末肺容积变化、动态顺应性以及氧饱和度与吸入氧分数之比（SpO/FiO）。
结果/发现：达到了招募、保留和缺失数据的可行性标准。未达到入选和方案依从性标准，818名患者符合入选条件，58名患者入组；心脏手术是排除的主要原因。约30%的患者至少有一次不依从情况。接受NSI的儿童VAP发生率降低；然而，这未达到统计学显著性（发生率比=0.12，95%置信区间=0.01 - 1.10；p = 0.06）。NSI与吸痰后长达10分钟时SpO/FiO比值显著降低相关。RM与VAP发生率降低无关（发生率比=0.31，95%置信区间=0.05 - 1.88），但在吸痰后2分钟和5分钟时确实显著改善了呼气末肺容积、动态顺应性以及SpO/FiO比值。
RM在短期内改善了呼气末肺容积和氧合。吸痰时进行NSI导致VAP发生率降低；然而，需要进行确定性的随机对照试验来检验统计学差异。对研究干预措施进行随机对照试验是值得的，并且通过修改方案（包括扩大参与者入选标准）可能是可行的。
