薄禄龙：Novel preventive strategies for ventilator-associated pneumonia: an evidence based perspective
Ventilator-associated pneumonia (VAP) is a complication of mechanical ventilation and is defined as the occurrence of pneumonia in patients under mechanical ventilation for at least 48 hours. The incidence of VAP ranges from 15% to 20% and the VAP-associated mortality is 20% to 70%. In recent years, a number of novel strategies were introduced to prevent VAP, including the optimal timing (early vs late) of tracheotomy, subglottic secretion drainage, and probiotics. We summarized these strategies systematically to generate the best evidence for VAP prevention.
A systematic literature search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Cochrane Central Register of Controlled Trials, the National Research Register, the National Health Service Trusts Clinical Trials Register, and the Medical Research Council UK database was conducted using specific search terms. Eligible randomized controlled studies (RCTs) which involved the comparison timing (early vs late) of tracheotomy, subglottic secretion drainage (SSD), and probiotics with controls, respectively, in critically ill adult patients were screened and selected for further analysis.
Seven trials with 1,044 patients were included to compare the effect of early tracheotomy (ET) verse late tracheotomy (LT). ET did not significantly reduce short-term mortality (relative risk [RR], 0.86; 95% CI, 0.65-1.13), long-term mortality (RR, 0.84; 95% CI, 0.68-1.04), or incidence of ventilator-associated pneumonia (RR, 0.94; 95% CI, 0.77-1.15) in critically ill patients.
Ten RCTs with 2,213 patients were identified to compare the effect of SSD in VAP prevention. SSD significantly reduced incidence of VAP (RR = 0.56, 95% CI: 0.45 to 0.69, P < 0.00001) and early-onset VAP (RR = 0.23, 95% CI: 0.13 to 0.43, P<0.00001), shortened ventilation duration by 1.55 days (95% CI: -2.40 to -0.71 days, P = 0.0003), and prolonged time to VAP by 3.90 days (95%CI: 2.56-5.24 days). Subgroup analyses suggested a significant reduction in incidence of VAP when stratified by intermittent (RR = 0.49, 95% CI: 0.34 to 0.71, P = 0.0001) and continuous SSD (RR=0.61, 95%CI: 0.46-0.79, P = 0.0003). No significant differences were observed regarding incidence of late-onset VAP, overall mortality or length of ICU or hospital stay.
Seven RCTs with 907 patients were included to compare the effect of probiotics and control in patients undergoing mechanical ventilation. Administration of probiotics was beneficial in terms of incidence of VAP (OR=0.56; 95% CI: 0.38-0.85), shortened the length of ICU stay by 1.2 days (95% CI: -1.56--0.74), and reduced colonization of the respiratory tract with Pseudomonas aeruginosa (OR=0.35; 95% CI, 0.12-0.73). However, no differences were observed regarding ICU mortality, in-hospital mortality, duration of mechanical ventilation.
Through an evidence-based method, we systematically reviewed roles of optimal timing (early vs late) of tracheotomy, SSD, and probiotics in VAP prevention. We confirmed that SSD and probiotics were beneficial in preventing VAP. However, the timing of the tracheotomy did not significantly alter important clinical outcomes in critically ill patients.
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