A Literature Review on Strategies Preventing Ventilator-Associated Pneumonia: Role of Endotracheal Cuff Pressure, Cuff Material, and Cuff Shape
DOI:
https://doi.org/10.1891/WFCCN-D-20-00004Keywords:
ventilator-associated pneumonia, endotracheal tube, cuff pressure, cuff material, cuff shapeAbstract
Objectives: To provide an overview of existing literature regarding the effects of ETT cuff pressure, cuff material, and cuff shape on VAP prevention in adult ventilated patients.
Background: Ventilated patients are at risk of ventilator-associated pneumonia (VAP), which can result in many adverse consequences, such as increased length of stay, mortality, and hospital cost. Endotracheal tube (ETT) insertion is a commonly used measure for mechanical ventilation. However, ETT cuff pressure, special cuff material, and special cuff shape may affect the occurrence of VAP in ventilated patients, but the evidence for their effects on VAP prevention has not been synthesized.
Methods: A literature review was conducted.
Findings: Twenty-two studies involving 8,809 patients were included in this literature review. The reviewed studies showed inconsistent findings of the effects of continuous ETT cuff pressure monitoring (compared with intermittent pressure monitoring), polyurethane ultrathin tracheal tube (compared with polyvinyl chloride tracheal tube), and taper-shaped cuff (compared with conical-shaped cuff) on the prevention of VAP. Two studies reported consistent findings that silver-coated ETT significantly reduced bacterial load and incidence of VAP compared with uncoated ETT, but the evidence level was relatively weak.
Conclusion: This literature review provides an initial and brief overview of the effects of ETT cuff pressure, cuff material, and cuff shape on preventing VAP. However, the effectiveness of these interventions remains inconclusive due to the inadequate evidence and low quality of previous studies. The intervention effects should be synthesized using a quantitative method and laboratory studies with rigorous design are needed to provide more solid evidence.
References
Bowton, D. L., Hite, R. D., Martin, R. S., & Sherertz, R. (2013). The impact of hospital-wide use of a tapered-cuff endotracheal tube on the incidence of ventilator-associated pneumonia. Respiratory Care, 58(10), 1582–1587. https://doi.org/10.4187/respcare.02278
Bulpa, P., Evrard, P., Bouhon, S., Schryvers, F., Jamart, J., Michaux, I., & Dive, A. (2013). Polyurethane does not protect better than polyvinyl cuffed tracheal tubes from microaspirations. Minerva Anestesiologica, 79(5), 498–503.
Carhart, E., Stuck, L. H., & Salzman, J. G. (2016). Achieving a safe endotracheal tube cuff pressure in the prehospital setting: Is it time to revise the standard cuff inflation practice?Prehospital Emergency Care Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 20(2), 273–277. https://doi.org/10.3109/10903127.2015.1061626
Dat, V. Q., Geskus, R. B., Wolbers, M., Loan, H. T., Yen, L. M., Binh, N. T., & Chien, L. T. (2018). Continuous versus intermittent endotracheal cuff pressure control for the prevention of ventilator-associated respiratory infections in Vietnam: Study protocol for a randomised controlled trial. Trials, 19(1), 217. https://doi.org/10.1186/s13063-018-2587-6
Dave, M. H., Frotzler, A., Spielmann, N., Madjdpour, C., & Weiss, M. (2010). Effect of tracheal tube cuff shape on fluid leakage across the cuff: an in vitro study. British Journal of Anaesthesia, 105(4), 538–543. https://doi.org/10.1093/bja/aeq202
de Lacerda Vidal, C. F., Vidal AKde, L., Monteiro JGde, M. J., Cavalcanti, A., Henriques, A. P., da, C., & Oliveira, M. (2017). Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: A randomized study. BMC Infectious Diseases, 17, 112. https://doi.org/10.1186/s12879-017-2188-0
De Pascale, G., Pennisi, M. A., Vallecoccia, M. S., Bello, G., Maviglia, R., Montini, L., & Di Gravio, V. (2017). CO2 driven endotracheal tube cuff control in critically ill patients: A randomized controlled study. PLOS ONE, 12, e0175476. https://doi.org/10.1371/journal.pone.0175476
Erb, C. T., Patel, B., Orr, J. E., Bice, T., Richards, J. B., Metersky, M. L., & Wilson, K. C. (2016). Management of Adults with Hospital-acquired and Ventilator-associated Pneumonia. Annals of the American Thoracic Society. 13(12), 2258–2260. https://doi.org/10.1513/AnnalsATS.201608-641CME
Guerra, F., De Martino, F., Capocci, M., Rinaldo, F., Mannocci, A., De Biase, A., & Ottolenghi, L. (2016). VAP and oral hygiene. A systematic review. La Clinica Terapeutica, 167(6), 198–205.
Hamilton, V. A., & Grap, M. J. (2012). The role of the endotracheal tube cuff in microaspiration. Heart & Lung The Journal of Critical Care, 41(2), 167–172. https://doi.org/10.1016/j.hrtlng.2011.09.001
Harbrecht, B. G. (2012). Head of bed elevation and ventilator-associated pneumonia. Respiratory Care, 57(4), 659–660. https://doi.org/10.4187/respcare.01797
Jaillette, E., Girault, C., Brunin, G., Zerimech, F., Behal, H., Chiche, A., & Broucqsault-Dedrie, C. (2017). Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: A multicenter cluster-randomized cross-over controlled trial. Intensive Care Medicine, 43(11), 1562–1571. https://doi.org/10.1007/s00134-017-4736-x
Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., & Napolitano, L. M. (2016). Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the infectious diseases society of America and the American Thoracic Society. Clinical Infectious Diseases An Official Publication of the Infectious Diseases Society of America. 63(5), e61–e111. https://doi.org/10.1093/cid/ciw353
Kollef, M. H. (2005). What is ventilator-associated pneumonia and why is it important?Respiratory Care, 50(6), 714.
Kollef, M. H., Afessa, B., Anzueto, A., Veremakis, C., Kerr, K. M., Margolis, B. D., & Craven, D. E. (2008). Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: The NASCENT randomized trial. JAMA, 300(7), 805–813. https://doi.org/10.1001/jama.300.7.805
Kollef, M. H., Hamilton, C. W., & Ernst, F. R. (2012). Economic impact of ventilator-associated pneumonia in a large matched cohort. Infection Control and Hospital Epidemiology, 33(3), 250–256. https://doi.org/10.1086/664049
Kwan, A. M., Chan, K., Lau, A. C., & Yan, W. (2012). Ventilator associated pneumonia in intensive care unit Incidence, patient characteristics, outcome and validation of VAP-PIRO score in a local Chinese cohort. Critical Care & Shock, 15(4), 111–119.
Lambert, M. L., Suetens, C., Savey, A., Palomar, M., Hiesmayr, M., Morales, I., & Agodi, A. (2011). Clinical outcomes of health-care-associated infections and antimicrobial resistance in patients admitted to European intensive-care units: A cohort study. The Lancet. Infectious Diseases, 11(1), 30–38. https://doi.org/10.1016/S1473-3099(10)70258-9
Letvin, A., Kremer, P., Silver, P. C., Samih, N., Reed-Watts, P., & Kollef, M. H. (2018). Frequent versus infrequent monitoring of endotracheal tube cuff pressures. Respiratory Care, 63(5), 495–501. https://doi.org/10.4187/respcare.05926
Lorente, L., Lecuona, M., Jimenez, A., Cabrera, J., & Mora, M. L. (2014a). Subglottic secretion drainage and continuous control of cuff pressure used together save health care costs. American Journal of Infection Control, 42(10), 1101–1105. https://doi.org/10.1016/j.ajic.2014.06.028
Lorente, L., Lecuona, M., Jimenez, A., Lorenzo, L., Roca, I., Cabrera, J., & Llanos, C. (2014b). Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia. Critical Care, 18(2), R77. https://doi.org/10.1186/cc13837
Lorente, L., Lecuona, M., Jimenez, A., Mora, M. L., & Sierra, A. (2007). Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. American Journal of Respiratory and Critical Care Medicine, 176(11), 1079–1083. https://doi.org/10.1164/rccm.200705-761OC
Lucangelo, U., Zin, W. A., Antonaglia, V., Petrucci, L., Viviani, M., Buscema, G., & Borelli, M. (2008). Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. Critical Care Medicine, 36(2), 409–413. https://doi.org/10.1097/01.CCM.0000297888.82492.31
Mahmoodpoor, A., Hamishehkar, H., Hamidi, M., Shadvar, K., Sanaie, S., Golzari, S. E., & Khan, Z. H. (2017). A prospective randomized trial of tapered-cuff endotracheal tubes with intermittent subglottic suctioning in preventing ventilator-associated pneumonia in critically ill patients. Journal of Critical Care, 38, 152–156. https://doi.org/10.1016/j.jcrc.2016.11.007
Mahmoodpoor, A., Peyrovi-far, A., Hamishehkar, H., Bakhtyiari, Z., Mirinezhad, M. M., Hamidi, M., & Golzari, S. E. J. (2013). Comparison of prophylactic effects of polyurethane cylindrical or tapered cuff and polyvinyl chloride cuff endotracheal tubes on ventilator-associated pneumonia. Acta Medica Iranica, 51(7), 461–466.
Mareiniss, D. P., Xu, T., Pham, J. C., Hsieh, Y. H., Zhao, J., Nguyen, C., & Nguyen, M. (2016). Predicting which patients will likely benefit from subglottic secretion drainage endotracheal tubes: A retrospective study. The Journal of Emergency Medicine, 50(3), 385–393. https://doi.org/10.1016/j.jemermed.2015.10.039
Melsen, W. G., Rovers, M. M., Groenwold, R. H. H., Bergmans, D. C. J. J., Camus, C., Bauer, T. T., & Hanisch, E. W. (2013). Attributable mortality of ventilator-associated pneumonia: A meta-analysis of individual patient data from randomised prevention studies. The Lancet. Infectious Diseases, 13(8), 665–671. https://doi.org/10.1016/S1473-3099(13)70081-1
Metersky, M. L., & Kalil, A. C. (2018). Management of ventilator-associated pneumonia: Guidelines. Clinics in Chest Medicine, 39(4), 797–808. https://doi.org/10.1016/j.ccm.2018.08.002
Miller, M. A., Arndt, J. L., Konkle, M. A., Chenowethm, C. E., Iwashyna, T. J., Flaherty, K. R., & Hyzy, R. C. (2011). A polyurethane cuffed endotracheal tube is associated with decreased rates of ventilator-associated pneumonia. Journal of Critical Care, 26(3), 280–286. https://doi.org/10.1016/j.jcrc.2010.05.035
Millot, G., Boddaert, P., Parmentier-Decrucq, E., Palud, A., Balduyck, M., Maboudou, P., & Zerimech, F. (2018). Impact of subglottic secretion drainage on microaspiration in critically ill patients: A prospective observational study. Annals of Translational Medicine, 6(21), 416. https://doi.org/10.21037/atm.2018.10.44
Monsel, A., Lu, Q., Le Corre, M., Brisson, H., Arbelot, C., Vezinet, C., & Fleron, M. H. (2016). Tapered-cuff endotracheal tube does not prevent early postoperative pneumonia compared with spherical-cuff endotracheal tube after major vascular surgery. Anesthesiology, 124, 1041–1052. https://doi.org/10.1097/ALN.0000000000001053
Muscedere, J., Rewa, O., McKechnie, K., Jiang, X., Laporta, D., & Heyland, D. K. (2011). Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. Critical Care Medicine, 39(8), 1985–1991. https://doi.org/10.1097/CCM.0b013e318218a4d9
Niel-Weise, B. S., Gastmeier, P., Kola, A., Vonberg, R. P., Wille, J. C., & van den Broek, P. J. (2011). An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Critical Care, 15(2), R111. https://doi.org/10.1186/cc10135
Nseir, S., Zerimech, F., Fournier, C., Lubret, R., Ramon, P., Durocher, A., & Balduyck, M. (2011). Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. American Journal of Respiratory and Critical Care Medicine, 184(9), 1041–1047. https://doi.org/10.1164/rccm.201104-0630OC
Ouanes, I., Lyazidi, A., Danin, P. E., Rana, N., Di Bari, A., Abroug, F., & Louis, B. (2011). Mechanical influences on fluid leakage past the tracheal tube cuff in a benchtop model. Intensive Care Medicine, 37(4), 695–700. https://doi.org/10.1007/s00134-011-2145-0
Philippart, F., Gaudry, S., Quinquis, L., Lau, N., Ouanes, I., Touati, S., & Nguyen, J. C. (2015). Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients. American Journal of Respiratory and Critical Care Medicine, 19(9), 637–645. https://doi.org/10.1164/rccm.201408-1398OC
Poelaert, J., Depuydt, P., De Wolf, A., Van de Velde, S., Herck, I., & Blot, S. (2008). Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: A pilot study. The Journal of Thoracic and Cardiovascular Surgery, 135(4), 771–776. https://doi.org/10.1016/j.jtcvs.2007.08.052
Rello, J., Kollef, M., Diaz, E., Sandiumenge, A., del Castillo, Y., Corbella, X., & Zachskorn, R. (2006). Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study. Critical Care Medicine, 34(11), 2766–2772. https://doi.org/10.1097/01.CCM.0000242154.49632.B0
Rosenthal, V. D., Bijie, H., Maki, D. G., Mehta, Y., Apisarnthanarak, A., Medeiros, E. A., & Leblebicioglu, H. (2012). International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004–2009. American Journal of Infection Control, 40(5), 396–407. https://doi.org/10.1016/j.ajic.2011.05.020
Rosenthal, V. D., Maki, D. G., Jamulitrat, S., Medeiros, E. A., Todi, S. K., Gomez, D. Y., & Leblebicioglu, H. (2010). Summary for 2003-2008. International Nosocomial Infection Control Consortium (INICC) Report, Data, American Journal of Infection Control, 38(2), 95–104.e2. https://doi.org/10.1016/j.ajic.2009.12.004
Rouze, A., Jaillette, E., Poissy, J., Preau, S., & Nseir, S. (2017). Tracheal tube design and ventilator-associated pneumonia. Respiratory Care, 62(10), 1316–1323. https://doi.org/10.4187/respcare.05492
Sole, M. L., Su, X., Talbert, S., Penoyer, D. A., Kalita, S., Jimenez, E., & Ludy, J. E. (2011). Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range. American Journal of Critical Care, 20(2), 109–118. https://doi.org/10.4037/ajcc2011661
Suhas, P., Kundra, P., & Cherian, A. (2016). Polyurethane cuffed versus conventional endotracheal tubes: Effect on ventilator-associated pneumonia rates and length of intensive care unit stay. Indian Journal of Anaesthesia, 60(3), 163–167. https://doi.org/10.4103/0019-5049.177871
Sundar, K. M., Nielsen, D., & Sperry, P. (2012). Comparison of ventilator-associated pneumonia (VAP) rates between different ICUs: Implications of a zero VAP rate. Journal of Critical Care, 27(1), 26–32. https://doi.org/10.1016/j.jcrc.2011.05.019
Torres, A., Niederman, M. S., Chastre, J., Ewig, S., Fernandez-Vandellos, P., Hanberger, H., & KollefM. (2017). International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European. The European Respiratory Journal, 50(3), 1700582. https://doi.org/10.1183/13993003.00582-2017
Valencia, M., Ferrer, M., Farre, R., Navajas, D., Badia, J. R., Nicolas, J. M., & Torres, A. (2007). Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: A randomized trial. Critical Care Medicine, 35(6), 1624–1626. https://doi.org/10.1097/01.CCM.0000266686.95843.7D
Zuckerman, L. M. (2016). Oral chlorhexidine use to prevent ventilator-associated pneumonia in adults: review of the current literature. Dimensions of Critical Care Nursing DCCN, 35(1), 25–36. https://doi.org/10.1097/DCC.0000000000000154
