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Subglottic drainage
Combining the results of the four RCTs
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Combining the data from the 4 papers demonstrates a
significant reduction in the incidence of VAP with subglottic drainage of
secretions (NNT 12)
Grade of Recommendation: A |
Three-part Clinical
Question: In
the 4 papers reviewed, what is the overall evidence for the effect of subglottic
drainage on the incidence of ventilator associated pneumonia in ICU patients?
Search Terms: critical care; ventilation; subglottic drainage; pneumonia;
ventilator associated pneumonia
The Studies:
1) Smulders K, et al. A
randomized clinical trial of intermittent subglottic secretion drainage in
patients receiving mechanical ventilation. Chest 2002; 121: 858-862
2) Kollef M, et al. A randomised clinical trial of continuous aspiration of
subglottic secretions in cardiac surgery patients. Chest 1999; 116: 1339-1346
3) Valles J, et al. Continuous aspiration of subglottic secretions in preventing
ventilator-associated pneumonia. Ann Intern Med 1995; 122: 179-186
4) Mahul P, et al.
Prevention of nosocomial pneumonia in intubated patients: respective role of
mechanical subglottic secretions drainage and stress ulcer prophylaxis.
Intensive Care Medicine 1992; 18: 20-25
The Study Patients: Patients being ventilated in 4 ICU's
Control group (N = 428; 410 analysed): Control group received all
standard care. Study group had continuous or intermittent drainage of subglottic
secretions.
Experimental group (N = 400; 381 analysed): All patients observed until
extubation or death (or, in 1 study, development of VAP).
The Evidence:
|
Outcome |
Time to
Outcome |
CER |
EER |
RRR |
ARR |
NNT |
|
Incidence
of V.A.P. |
To end of
study period |
0.171 |
0.085 |
50% |
0.086 |
12 |
|
95% Confidence
Intervals: |
24% to 77% |
0.041 to 0.131 |
8 to 24 |
Comments:
Subglottic drainage is a simple and inexpensive therapy which has been
demonstrated in these 4 papers to reduce the incidence of VAP. The evidence in 3
of these papers also suggests that the time to onset of VAP is delayed, although
no overall effect on the number of ventilator days or mortality could be
demonstrated. Because it is inexpensive, and the NNT relatively small, it is
worth considering introducing this as one aspect of care aimed at preventing VAP
Appraised by: Joyce Stuart
Western General Hospital Edinburgh; 20 January 2004
Email:
Joyce.Stuart@luht.scot.nhs.uk
Kill or Update By: January 2009
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