2024年5月9日发(作者：水星路由器官网登录页面)

JournalofCriticalCare(2010)xx,xxx–xxx

Apolyurethanecuffedendotrachealtubeisassociatedwith

decreasedratesofventilator-associatedpneumonia

☆

MD

a,

⁎

,S,CIC

b

,MPA,RRT

c

,

ethMD

d

,naMD,PhD

e

,

tyMD,MS

e

,

e

a

DivisionofPulmonaryandCriticalCareMedicine,UniversityofMichigan,AnnArbor,MI

DepartmentofInfectionControlandEpidemiology,UniversityofMichigan,AnnArbor,MI

c

DepartmentofRespiratoryCare,UniversityofMichigan,AnnArbor,MI

d

DepartmentofInfectionControlandEpidemiology,DivisionofInfectiousDiseases,UniversityofMichigan,AnnArbor,MI

e

DivisionofPulmonaryandCriticalCareMedicine,UniversityofMichigan,AnnArbor,MI

b

Keywords:

Pneumonia,

Ventilator-associated;

Nosocomialinfections;

Ventilators,Mechanical;

Endotrachealtube

Abstract

Purpose:Theaimofthisstudywastodeterminewhethertheuseofapolyurethane-cuffedendotracheal

tubewouldresultinadecreaseinventilator-associatedpneumoniarate.

MaterialsandMethods:Wereplacedconventionalendotrachealtubewithapolyurethane-cuff

endotrachealtube(Microcuff,Kimberly-ClarkCorporation,Rosewell,Ga)inalladultmechanically

ventilatedp

retrospectivelycomparedtheratesofventilator-associatedpneumoniabefore,during,andafterthe

interventionyearbyinterruptedtime-seriesanalysis.

Results:Ventilator-associatedpneumoniaratesdecreasedfrom5.3per1000ventilatordaysbeforethe

useofthepolyurethane-cuffedendotrachealtubeto2.8per1000ventilatordaysduringtheintervention

year(P=.0138).Duringthefirst3monthsafterreturntoconventionaltubes,therateofventilator-

associatedpneumoniawas3.5/hepolyurethane-cuffedendotrachealtube

wasassociatedwithanincidenceriskratioofventilator-associatedpneumoniaof0.572(95%

confidenceinterval,0.340-0.963).Instatisticalregressionanalysiscontrollingforotherpossible

alterationsinthehospitalenvironment,asmeasuredbyrateoftracheostomy-ventilator-associated

pneumonia,theincidenceriskratioofventilator-associatedpneumoniainpatientsintubatedwith

polyurethane-cuffedendotrachealtubewas0.565(P=.032;95%confidenceinterval,0.335-0.953).

Conclusions:Useofapolyurethane-cuffedendotrachealtubewasassociatedwithasignificantdecrease

intherateofventilator-associatedpneumoniainourstudy.

©htsreserved.

Funding/Support:ThisstudywaspartiallyfundedbyKimberly-ClarkCorporation,Rosewell,Ga,ly-Clark

CorporationsuppliedtheMicrocuffpolyurely-ClarkCorporationemployees

werenotinvolvedintheconcept,design,orconductofthestudy,norweretheyinvolvedintheanalysisofdataorreviewofthemanuscriptbeforesubmission.

DrRobertHyzyhasreceivedaconsultingfeeof$5800in2008anda$6000unrestrictededucationalgrantin2007fromtheKimberly-ClarkCorporation.

⁎

Correspondingauthor.3916TaubmanCenter,AnnArbor,MI48109-5360,USATel.:+;fax:+.

E-mailaddress:melmille@().

0883-9441/$–seefrontmatter©htsreserved.

doi:10.1016/.2010.05.035

☆

2

uction

Ventilator-associatedpneumonia(VAP)isasignificant

causeofincreasedmorbidityandcostinmechanically

eenassociatedwithagreater

durationofmechanicalventilation,intensivecareunit(ICU)

andhospitallengthofstay,andestimatedcostsof$10000to

$40000perepisode[1-4].Ventilator-associatedpneumonia

increasesmortalityinmedicalintensivecarepatients[5],in

patientswhoseonsetofVAPisafter5daysofmechanical

ventilation[6],andinpatientswithVAPduetoPseudo-

monasaeruginosa[7].Despitesubstantialeffortsmadeto

preventVAP[8-10],theincidenceandimpactofVAP

remainsignificant[3,11].

OneproposedmechanismforthedevelopmentofVAPis

leakageofcolonizedoropharyngealsecretionsbeyondthe

endotrachealtube(ETT)cuffintothelowerrespiratorytract

[12-14].ConventionalETTsuseahigh-volume,low-

pressurepolyvinylcuffthatwasdevelopedtodecrease

ributecuff

pressureoveralargesurfacearea,thediameterofthecuffis

r,thisleadstothe

recommendedinflationpressureof20to30cmH

2

0[15],

oropharyngealsecretionseasilyleakthroughthesechannels

intothelowerairway[14].

SeveralETTshavebeendesignedtopreventpassageof

upperairwayoropharyngealsecretionsintothelower

respiratorytract[16-20].Subglotticsecretiondrainage

ETTs(SSD-ETTs)havebeenshowntobeeffectivein

decreasingVAPinpatientsrequiringmechanicalventilation

morethan72hours[18,21-24];however,theyhavehad

limitedutilization[25],ostensiblyduetodifficultyin

accuratelypredictingappropriatepatientsforuse,more

intensivenursingneedsassociatedwithmaintenanceofthe

suctionport,andhigherexpense[25,26].Inaddition,astudy

insheepshowedsignificantmucosaldamageassociatedwith

theuseoftheSSD-ETT[27].

PolyurethanecuffedETTs(PUC-ETT)havebeen

showntodecreaseleakageoforopharyngealsecretionsin

vitro[12,16].ThisETTcuffhasa7-μmwallthickness,

thinnerthantheusual50-μmthicknessseeninpolyvinyl

chloridecuffed(PVC)ethanecuffedETT

resultinatightertrachealsealatcuffinflationpressures

lessthan30cmH

2

Obyminimizingthedevelopmentof

largecuffchannels[12].PolyurethanecuffedETThas

beenshowntodecreasetheincidenceofVAPinsmall,

single-unitstudieswithhighbaselineratesofVAP[16,17],

butitseffectonVAPwhenusedinunselectedpatients,

includingemergentlyintubatedpatients,inroutinecareis

iedtheeffectofreplacingthe

conventionalPVC-ETTwiththePUC-ETTonthe

incidenceofVAPinpatientsthroughoutouradultICUs.

Weused2differentcontrolgroupstoovercomethe

,wecomparedVAPrates

withPUC-ETTwiththoseofpatientswithPVC-ETTboth

etal.

,wealso

usedVAPratesamongtracheostomypatientsduringthe

studyperiodtocontrolforsynchronousotherchangesin

ventilatorcareorhospitalmicrobiology.

alsandmethods

ocationandpatients

Thisstudywasconductedatasinglestudysite,the

UniversityofMichigan,UniversityHospitalinAnnArbor,

MI,a27-

monthperiod,July2006toSeptember2008,adultpatientsin

ICUsintubatedformechanicalventilationwithanETTwere

patientswith

tracheostomytubesreceivingmechanicalventilationwere

participatingICUswerethetrauma-burnintensivecareunit

(TBICU;10beds),thecardiacintensivecareunit(CICU;10

beds),thecriticalcaremedicineunit(CCMU;20beds),the

neurointensivecareunit(NICU;10beds,increasedto15beds

duringthestudyperiod),andthesurgicalintensivecareunit

(SICU;20beds).Duringtheinterventionyear,1ICU,the

thoracicICU,movedintoabuildingofnewconstructionand

morethandoubledinsize,ajor

changesinstaffing,staffeducation,andlogistics,patientsin

racteristicsof

eachincludedICUaresummarizedinTable1.

ThisstudywasreviewedbytheUniversityofMichigan

InstitutionalReviewBoard,asaretrospectivelyanalyzed

qualityimprovementprojectafterachangeinequipment.

ention

InJuly2007,wereplacedourconventionalPVC-ETT

withaPUC-ETT(Microcuff;KimberlyClarkCorporation,

Rosewell,Ga)throughoutouradultacademicinstitutionfor

1year(July2007-June2008).Thesetubeswereprovided

2008,our

institutionreturnedtotheuseofconventionalPVC-ETTs

inanticipationofinternalanalysisofeffectivenessandcost.

llectionanddefinitions

Dataregardinghospital-acquiredinfectionsareroutinely

prospectivelycollectedbyprofessionalsintheDepartment

ofInfectionControlandEpidemiologyonallpatients

withinourinstitutionforinternalqualityassurance.A

diagnosisofVAPismadeifthepatienthasbeenintubated

atleast48hoursandmeetsourinstitution'sclinicalor

microbiologiccriteria,basedonthestandardNational

HealthcareSafetyNetwork(NHSN)definition(seeAppen-

dixFigure1).Inourstudy,onlythefirstdiagnosisofVAP

wasincluded;patientdayssubsequenttofirstdiagnosisof