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

https://doi.org/10.1016/j.amjmed.2004.07.051Get rights and content

Purpose

To assess the efficacy of subglottic secretion drainage in preventing ventilator-associated pneumonia.

Methods

We performed a comprehensive, systematic meta-analysis of randomized trials that have compared subglottic secretion drainage with standard endotracheal tube care in mechanically ventilated patients. Studies were identified by a computerized database search, review of bibliographies, and expert consultation. Summary risk ratios or weighted mean differences with 95% confidence intervals were calculated for each outcome using a fixed-effects model.

Results

Of 110 studies retrieved, five met the inclusion criteria and enrolled 896 patients. Subglottic secretion drainage reduced the incidence of ventilator-associated pneumonia by nearly half (risk ratio [RR] = 0.51; 95% confidence interval [CI]: 0.37 to 0.71), primarily by reducing early-onset pneumonia (pneumonia occurring within 5 to 7 days after intubation). Although significant heterogeneity was found for several endpoints, this was largely resolved by excluding a single outlying study. In the remaining four studies, which recruited patients expected to require >72 hours of mechanical ventilation, secretion drainage shortened the duration of mechanical ventilation by 2 days (95% CI: 1.7 to 2.3 days) and the length of stay in the intensive care unit by 3 days (95% CI: 2.1 to 3.9 days), and delayed the onset of pneumonia by 6.8 days (95% CI: 5.5 to 8.1 days).

Conclusion

Subglottic secretion drainage appears effective in preventing early-onset ventilator-associated pneumonia among patients expected to require >72 hours of mechanical ventilation.

Section snippets

Data sources

Two authors (CD, KS) independently searched the MEDLINE, CINAHL, EMBASE, Cochrane Library, Current Contents, and Biological Abstracts databases for relevant studies in any language from January 1966 to May 2003, using exploded Medical Subject Headings or the appropriate corresponding keywords glottis or suction or drainage and respiration, artificial or ventilation, mechanical and pneumonia. The titles and abstracts of all the articles were scanned, and potentially relevant articles and reviews

Study selection

The MEDLINE search retrieved 110 citations, of which five met our inclusion criteria (Table 1). A total of 896 patients were evaluated in these five trials; four of these studies were in English and one was in Chinese. We excluded one study 26 that evaluated the technique of subglottic secretion drainage in 10 patients with tracheostomies because of lack of a control group. The remaining 104 citations fell into one or more of the following exclusionary categories: noninterventional studies

Discussion

We found that the use of subglottic secretion drainage in mechanically ventilated patients reduces the risk of ventilator-associated pneumonia by nearly 50%. Additionally, subglottic secretion drainage results in marked reductions in the duration of mechanical ventilation and ICU stay. In sensitivity analyses, the benefits of subglottic secretion drainage were most substantial when this technique was applied to patients expected to be mechanically ventilated for >72 hours. In this patient

Acknowledgment

We are indebted to Wei Ming Sun, MD, PhD, Department of Internal Medicine, University of Michigan, for assistance with translation of the study by Bo et al20 into English. We thank Marin Kollef, MD, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine; Jordi Vallés, MD, Intensive Care and Microbiology Departments, Hospital de Sabadell, Barcelona, Spain; and Andrew F. Shorr, MD, MPH, Walter Reed Army Medical Center for responding to our requests for more

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    Dr. Saint is supported by a Career Development Award from the Health Services Research and Development Program of the Department of Veterans Affairs, and a Patient Safety Developmental Center Grant from the Agency for Healthcare Research and Quality (P20-HS11540). Dr. Matthay is supported by National Institutes of Health Grants HL51854, HL51856, and PSOHL74005.

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