Essay: Ventilation-Associated Pneumonia Prevention

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Subglottic Drainage

Subglottic secretion drainage for preventing ventilator associated pneumonia: A meta-analysis

It has been established that the incidents of ventilation-associated pneumonia could be reduced by almost half by the use of endotracheal tubes. This would assist in reducing the morbidity and mortality rates of the patients. It is estimated that VAP affects around nine -27% of the intubated patients who are receiving mechanical ventilation. This is a large number considering that using subglottic secretion drainage has the capability to reduce the incident rates. Frost et al. (2013) conducted a meta-analysis that combined information from published studies on the effect of subglottic drainage of secretions on VAP incidents in adult ICU patients. The researchers established that using subglottic drainage of secretions reduced the risk of VAP by almost 48%. The researchers discovered there was no considerable reduction in the mortality rates in both the ICU and hospital from the published studies. The time a patient spends on a mechanical ventilation could be reduced. Time before a patient develops a VAP is increased when using specialized endotracheal tubes that are designed to drain subglottic secretions. VAP has been associated with substantial morbidity and mortality in the ICU. The possibility of preventing VAP is increased when using SSD. The draining of secretions should be carried out in scheduled intervals with a minimum of one hour and maximum of 4 hours. This would ensure that there is no overflow and risk of the discharge flowing back to the patient's body. The head elevation is also vital to ensure that the discharge flows outward. The elevation should be between 30-40 degrees.

Intermittent Subglottic Secretion Drainage and Ventilator-associated Pneumonia

The use of subglottic secretion drainage (SSD) has remained a controversial subject since the studies conducted have differing points-of-view (Lacherade et al., 2010b). The single center trials conducted by Valles and Artigas (1995) and Bouza et al. (2008) did not confirm that the use of SSD did in fact reduce the incidence of VAP. A meta-analysis conducted on these studies by Dezfulian et al. (2005) concluded in their study that there was an effective reduction in the early-onset rate of VAP when using SSD. In 2003 and 2004, SSD was not considered as a measure to prevent VAP in Canadian and United States guidelines. It was only suggested as a measure (Dodek et al., 2004). Currently, SSD is the recommended method for preventing VAP. A multicenter trial conducted by Lacherade et al. (2010b) at four French centers established that there was a considerable decrease in the rate of VAP when using SSD. The researchers also analyzed the incidence of early and late-onset of VAP. This randomized study involved patients above 18 years admitted to the ICU. The researchers screened for patients intubated with an endotracheal tube that allowed for subglottic secretion drainage. The patients were also expected to require at least 48 hours of mechanical ventilation in order to participate in the study.

The researchers had two randomly assign patients in order to have a controlled group and SSD group. Each group consisted of 220 patients, which allowed for detection of any differences. The study period lasted for 3 years, and at the end of it only 333 patients were included. The subglottic secretions were manually suctioned once every hour. There were daily screening for any occurrence of VAP for all the randomized patients. The screening was maintained until the first episode of VAP occurred. Diagnosis of pneumonia within the first 48 hours of the ventilation onset was not considered as caused as ventilator-associated. Early-onset was determined to occur within five days of the mechanical ventilation initiation and late-onset occurred after the five days. The researchers did not assess late-onset for patients who did not undergo mechanical ventilation, but they assessed the early-onset for all the patients. The study confirmed that SSD reduces VAP incidents. VAP occurred in 14.8% of the SSD group and 25.6% in the control group. For the patients in the SSD group, early and late-onset of VAP was reduced significantly. In the SSD group early onset was 1.2% and late onset was 18.3%. For the control group, early onset was 6.1% and late onset was 33%. There was no substantial difference in the duration of stay in the ICU for both groups (Bouza et al., 2003). The study indicated that there is a possibility of reducing the risk of VAP by using SSD by 11%.

Subglottic secretion drainage for preventing ventilator-associated pneumonia

The meta-analysis initially retrieved 110 studies, but only five studies met the researchers' criteria. Four of the studies were in English and one in Chinese. The researchers attempted to identify unpublished data, which would assist in reducing any publication bias, but they did not access this fact. One of the five chosen studies was excluded since it did not include a control group. The researchers employed methodologies that allowed for error and bias minimization during data extraction. The risk of VAP is reduced by almost 50% when using SSD. The researchers also established that the duration mechanical ventilation and stay in the ICU were reduced. Mechanical ventilation days were reduced by 2 days, while ICU stay reduced by 3 days. Heyland et al. (1999) who calculated a 3-day reduction in the ICU stay supported this. The early-onset of VAP was also found to reduce using SSD. SSD is not effective in preventing late-onset of VAP. This is because gram-negative bacilli and P. aeruginosa the common causes of late-onset VAP colonize the trachea before they appear in the subglottic secretions or oropharyngeal. For the patients who require mechanical ventilation for less than 72 hours, the meta-analysis identified that SSD was far less effective. The reason for this is that accumulation of contaminated subglottic secretions requires a couple of days for them to take place. Patients who require short-term mechanical ventilation have reduced benefits when compared to long-term patients. This fact is supported by Kollef et al. (1999) in the study of postoperative patients where the mean duration for mechanical ventilation was 2 days or less. The meta-analysis revealed that SSD was cost effective for patients requiring prolonged mechanical ventilation. Though this was not a formal economic evaluation, the researchers identified that there was a saving of $3,535 per pneumonia case. Complications related to SSD are few, and in the studies involved in the analysis, no single complication was reported.

The potential for omitting relevant studies is evident in meta-analyses, which the researchers have confirmed as a limitation to their study. Performing a thorough database search might have eliminated this limitation, but there are still some relevant studies they might have missed. To ensure that they incorporated quality studies, the researchers employed different checklists and scales. The study confirmed that the use of SSD does in fact reduce VAP, shorten the duration of a patient in ICU, and shorten the duration of mechanical ventilation. The meta-analysis established that patients who received SSD reduced their risk to early onset pneumonia when compared to those who received standard endotracheal tube. The number of mechanical ventilation required by SSD patients was 1.8 days fewer. Between the two groups under study, there was no significant difference in the mortality and length of stay in hospital.

Critical analysis of care given to patient

The patient was intubated with an endotracheal tube that had suction above the cuff. The tube had the capability to secrete subglottic discharge, which ensured that there was no accumulation of secretions within the body. The patient was given good care, especially considering that they developed a condition that is associated with the intubated tube. Various studies have indicated that the best way to discharge the subglottic secretions is using SSD, but the studies also indicate that there is a likelihood of the patient developing VAP. SSD only delays the onset of VAP, but does not have the capability to prevent. There are other ways proposed to reduce the onset of VAP in intubated patients. Oral health of the patient would ensure that no oral secretions accumulate on the tracheal cuff, which would leak into the lungs. Oral health has also been identified as effective in reducing the risk of VAP (Kollef, 1999).

Draining the pleural effusions provides the patient with much needed relief. The 61-year-old patient did not have the strength to endure the pain caused by the effusions, and they did receive relief once they were intubated. A 2012 study by Fysh et al. (2012) found that the patient who chose to use a discharge tube spent less days in hospital, had less recurrence of effusion, and quick improvement in the quality of their life as compared to patients who opt for other methods. Another study determined that the drainage of pleural effusion in patients on mechanical ventilation was safe, and it appeared to improve oxygenation Goligher et al. (2011). There was no information supporting or refuting the benefits of clinical outcomes like duration of stay or duration of ventilation. There is a reduction in relative risk and improvement of the patient's… [END OF PREVIEW]

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