Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, QLD, Australia.
Crit Care Med. 2022 Oct 1;50(10):1430-1439. doi: 10.1097/CCM.0000000000005630. Epub 2022 Jul 26.
Microaspiration of subglottic secretions is the main pathogenic mechanism for ventilator-associated pneumonia (VAP). Adequate inflation of the endotracheal cuff is pivotal to providing an optimal seal of the extraluminal airway. However, cuff pressure substantially fluctuates due to patient or tube movements, which can induce microaspiration. Therefore, devices for continuous cuff pressure control (CCPC) have been developed in recent years. The purpose of this systematic review and meta-analysis is to assess the effectiveness of CCPC in VAP prevention.
A systematic search of Embase, the Cochrane Central Register of Controlled Trials, and the International Clinical Trials Registry Platform was conducted up to February 2022.
Eligible studies were randomized controlled trials (RCTs) and quasi-RCTs comparing the impact of CCPC versus intermittent cuff pressure control on the occurrence of VAP.
Random-effects meta-analysis was used to calculate odds ratio (OR) and 95% CI for VAP incidence between groups. Secondary outcome measures included mortality and duration of mechanical ventilation (MV) and ICU stay. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.
Eleven RCTs with 2,092 adult intubated patients were included. The use of CCPC was associated with a reduced risk of VAP (OR, 0.51). Meta-analyses of secondary endpoints showed no significant difference in mortality but significant differences in durations of MV (mean difference, -1.07 d) and ICU stay (mean difference, -3.41 d) in favor of CCPC. However, the risk of both reporting and individual study bias was considered important. The main issues were the lack of blinding, potential commercial conflicts of interest of study authors and high heterogeneity due to methodological differences between studies, differences in devices used for CCPC and in applied baseline preventive measures. Certainty of the evidence was considered "very low."
The use of CCPC was associated with a reduction in VAP incidence; however, this was based on very low certainty of evidence due to concerns related to risk of bias and inconsistency.
下呼吸道分泌物微吸入是呼吸机相关性肺炎（VAP）的主要发病机制。气管内套囊充分充气对于提供最佳的气道腔外密封至关重要。然而，由于患者或导管移动，套囊压力会发生显著波动，这可能会导致微吸入。因此，近年来已经开发出用于连续套囊压力控制（CCPC）的设备。本系统评价和荟萃分析的目的是评估 CCPC 在预防 VAP 方面的有效性。
对 Embase、Cochrane 对照试验中心注册库和国际临床试验注册平台进行了系统搜索，检索时间截至 2022 年 2 月。
纳入了比较 CCPC 与间歇性套囊压力控制对 VAP 发生影响的随机对照试验（RCT）和准 RCT。
使用随机效应荟萃分析计算组间 VAP 发生率的比值比（OR）和 95%置信区间。次要结局指标包括死亡率以及机械通气（MV）和 ICU 住院时间。使用推荐评估、制定与评价方法评估证据确定性。
纳入了 11 项包含 2092 例成年插管患者的 RCT。使用 CCPC 可降低 VAP 的风险（OR，0.51）。对次要终点的荟萃分析显示，死亡率无显著差异，但 CCPC 有利于 MV（平均差值，-1.07 天）和 ICU 住院时间（平均差值，-3.41 天）的缩短。然而，报告偏倚和个体研究偏倚的风险被认为很重要。主要问题是缺乏盲法、研究作者潜在的商业利益冲突以及由于研究方法学差异、CCPC 所用设备和应用的基线预防措施不同而导致的高度异质性。证据确定性被认为是“极低”。
使用 CCPC 与 VAP 发生率的降低相关；然而，由于存在与偏倚风险和一致性相关的担忧，证据的确定性非常低。
