Role of the endotracheal tube in VAP - Assistance Publique ...

Ventilator-Associated
Pneumonia
The role of the endotracheal tube
Dr Emmanuelle Girou
Hôpital Henri Mondor, Créteil Cr Créteil teil
Assistance Publique – Hôpitaux de Paris
Université Universit Université Paris 12

VAP
Pathogenesis
Estes et al.
ICM 1995;21:365

Airway
Colonisation
Patients ventilated
at least 5 days
Girou et al.
ICM 2004

Hanson et al.
Endotracheal intubation
Celis et al.
Endotracheal intubation
Goldmann et al.
Endotracheal intubation
Cook et al.
MV in the previous 24h
Van der Sar et al.
Risk per day of MV
Cunnion et al.
MV more than one day
Torres et al.
MV more than 3 days
Vanhems et al.
MV more than 7 days
Memish et al.
MV more than 19 days
First Risk Factor of VAP:
Endotracheal intubation
Adjusted Odds
Ratio (95%CI)
5.2 (1.1-25.6)
6.7 (4.1-10.9)
7.0 (NA)
2.28 (1.11-4.68)
1.3 (1.0-1.6)
12.1 (NA)
1.17 (1.15-1.19)
2.1 (1.3-3.4)
10.2 (3.1-33.2)
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Girou. Clin Pulm Med 2001

Pathogenesis
Low level evidence

Mucus Shaver
Kolobow et et al. al. Anesthesiol 2005
Every 6 hours, after suctioning
Shaver
72h MV
New ETT
Controls
72h MV

Do not intubate!
intubate intubate!

Noninvasive Ventilation and VAP Prevention
Essais randomisés
Etudes de cohorte
Brochard, 1995
Kramer, 1995
Antonelli, 1998
Wood, 1998
Confalonieri, 1999
Antonelli, 2000
Nava, 1998
Guérin, 1997
Nourdine, 1999
Girou, 2000
Carlucci, 2001
Toutes les études
0 5 10 15 20 25 30 35 40 45 50
% de pneumopathies nosocomiales
Girou 2002 (Masson Book)

Noninvasive Ventilation and
Nosocomial Infections
Percentage of nosocomial infections
25 CMV (n=50)
20
15
10
5
0
NP UTI CRI
VNI (n=50)
Girou et al. JAMA 2000

Secular Trends in Mortality
and Use of NIV
in COPD and Severe CPE
Girou et al. JAMA 2003
Percentage of patients
Percentage of patients
Percentage of patients
100
90
80
70
60
50
40
30
20
10
0
50
45
40
35
30
25
20
15
10
5
0
40
35
30
25
20
15
10
5
0
1994
(n=39)
NIV use
NIV Use use
NI
Nosocomial
Infections
ICU Mortality
ICU
Mortality
1995
(n=52)
1996
(n=64)
1997
(n=61)
1998
(n=70)
1999
(n=63)
P

What Type of
Endotracheal Tube?

% d ’utilisation
100
80
60
40
20
Subglottic Secretions Suctioning
0
SSD Standard Equal use
France (n=72)
Canada (n=31)
Cook et al. CCM
Oct. 2000
CDC Recommendation 2003

�� Mahul et al. Intensive Intensive Care Care Med Med 1992
– Reduction VAP rates: 12,8% vs 29,1%, p 72h (n=150); Intermittent drainage
– Reduction of VAP rates: 6,4% vs 21,3%, p

Patient position

% d ’utilisation
60
50
40
30
20
10
0
Semirecumbent Body Position
Semirec Supine equal use
France (n=72)
Canada (n=31)
Cook et al. CCM
Oct. 2000
CDC Recommendation 2003

Supine body position as a risk factor for nosocomial pneumonia
in mechanically ventilated patients: a randomised trial
Drakulovic et al. Lancet. 1999;354:1851-8
1999;354:1851
1999;354:1851-8
45°
5% de PAVM 23% de PAVM
-78%
0°
Drakulovic et al. Lancet 1999

Limitations of the Drakulovic’s Study
�� Documented VAP:
– 2/39 vs 11/47: P=0.018
– 3/40 vs 11/47: P=O.O77
�� Semirecumbency was achieved and maintained by
dissemination of protractors to bedside nurses,
researcher measurements using a protractor 7–8 7 8 times
per day including weekends, trunk position checks
throughout the night by on-call on call physicians, notification
of the research team about any position change, and
frequent educational in-services.
in services.

13/112 (10.7%) vs 8/109 (6.5%)
P=0.381
Van Nieuwenhoven et al. CCM 2006

The daily risk of VAP was reduced in both
treatment groups compared with PLAC:
- 65%

Conclusion
��Measures Measures in the bundle:
– Non invasive ventilation
– Oral decontamination with 2% chlorhexidine
– Endotracheal tube with microcuff
– Adequate monitoring of cuff pressure
– Procedures Procedures for for weaning weaning to to limit limit duration duration of of MV MV
– Optimal Optimal use use of of sedation sedation
– Semirecumbent position?
– Subglottic drainage?