Abstract
Intubation is performed in a large proportion of critically ill patients. Underinflation (< 20 cmH2O) and overinflation (> 30 cmH2O) of tracheal cuff were identified as risk factors for microaspiration and tracheal ischemic lesions, respectively. Maintaining cuff pressure (Pcuff) around 25 cmH2O is recommended to prevent these complications. Periodic adjustment of Pcuff using a manual manometer might be helpful in preventing severe tracheal ischemic lesions. However, despite manual control of Pcuff, patients spend a large amount of time with underinflation of Pcuff. Two randomized controlled studies evaluated the impact of continuous control of Pcuff on microaspiration of gastric contents and ventilation-acquired pneumonia (VAP) incidence. The first study using an electronic device failed to demonstrate any impact of continuous control of Pcuff on VAP rate (15% in the two groups). However, the second one found the pneumatic device to be associated with significantly reduced microaspiration of gastric contents, tracheobronchial colonization, and VAP rate (9.8% vs. 26.2%, p = 0.032, odds ratio [95%confidence interval] 0.30 [0.11–0.84]). Different devices and different patient characteristics might explain the different results found in these studies. Further randomized controlled multicenter trials are needed to determine the impact of continuous control of Pcuff on VAP incidence, and to compare the different available devices.
Résumé
L’intubation est réalisée chez un pourcentage important de patients hospitalisés en réanimation. Les souspressions (< 20 cmH2O) et surpressions (> 30 cmH2O) du ballonnet trachéal ont été identifiées comme facteurs de risque de micro-inhalation et d’ischémie trachéale, respectivement. Le maintien de la pression du ballonnet (Pbal) autour de 25 cmH2O est recommandé pour prévenir ces complications en réalisant un ajustement périodique de la Pbal avec un manomètre manuel. Cependant, en dépit de ce contrôle, les patients passent un pourcentage important du temps avec une sous-pression du ballonnet trachéal. Deux études ont évalué les effets de la régulation continue de la Pbal sur la survenue de micro-inhalations et de pneumonie acquise sous ventilation mécanique (PAVM). La première qui a utilisé un appareil électronique pour le contrôle continu de la Pbal n’a pas retrouvé de bénéfice de l’utilisation de ce type d’appareil en termes d’incidence de la PAVM (15 % dans les deux groupes). La seconde a démontré que la régulation continue de la Pbal par un appareil pneumatique permettait de réduire significativement l’incidence des micro-inhalations du liquide gastrique, de la colonisation trachéobronchique et des PAVM (9,8 vs 26,2 %, p = 0,032, odds ratio [intervalle de confiance à 95 %]: 0,30 [0,11–0,84]). Plusieurs différences entre ces études pourraient expliquer les résultats discordants: appareil électronique versus pneumatique, pourcentages des patients chirurgicaux et des patients présentant une PAVM dans le groupe témoin différents entre les deux études. D’autres études randomisées contrôlées multicentriques sont nécessaires afin de déterminer l’impact de la régulation continue de la Pbal sur l’incidence des PAVM et de comparer les différents appareils disponibles.
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Nseir, S., Jaillette, E. Continuous control of tracheal cuff pressure and ventilator-associated pneumonia. Réanimation 22, 245–249 (2013). https://doi.org/10.1007/s13546-013-0674-y
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DOI: https://doi.org/10.1007/s13546-013-0674-y