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首页> 外文期刊>BMC Infectious Diseases >How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients
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How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients

机译：如何避免微吸？预防插管ICU患者呼吸机相关性肺炎的关键因素

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Microaspiration of subglottic secretions through channels formed by folds in high volume-low pressure poly-vinyl chloride cuffs of endotracheal tubes is considered a significant pathogenic mechanism of ventilator-associated pneumonia (VAP). Therefore a series of prevention measures target the avoidance of microaspiration. However, although some of these can minimize microaspiration, benefits in terms of VAP prevention are not always obvious. Polyurethane-cuffed endotracheal tubes successfully reduce microaspiration but high quality data demonstrating VAP rate reduction are lacking. An analogous conclusion can be made regarding taper-shaped cuffs compared with classic barrel-shaped cuffs. More clinical data regarding these endotracheal tube designs are needed to demonstrate clinical value in addition to in vitro-based evidence. The clinical usefulness of endotracheal tubes developed for subglottic secretions drainage is established in multiple studies and confirmed by meta-analysis. Any change in cuff design will fail to prevent microaspiration if the cuff is insufficiently inflated. At least one well-designed trial demonstrated that continuous cuff pressure monitoring and control decrease the risk of VAP. Gel lubrication of the cuff prior to intubation temporarily hampers microaspiration through sludging the channels formed by folds in high volume-low pressure cuffs. As the beneficial effect of gel lubrication is temporarily, its potential to reduce VAP risk is probably nonsignificant. A minimum positive end-expiratory pressure of at least 5 cmH2O can be recommended as it reduces the risk of microaspiration in vitro and in vivo. One randomized controlled study demonstrated a reduced risk of VAP in patients ventilated with PEEP (5–8 cmH2O). Regarding head-of-bed elevation, it can be recommended to avoid supine positioning. Whether a 45° head-of-bed elevation is to be preferred above 25-30° head-of-bed elevation remains unproven. Finally, the routine monitoring of gastric residual volumes in mechanically ventilated patients receiving enteral nutrition cannot be recommended.
机译：通过气管插管的高容量-低压聚氯乙烯袖带中的褶皱形成的通道，通过声带抽吸声门下分泌物被认为是呼吸机相关性肺炎（VAP）的重要致病机制。因此，一系列预防措施的目标是避免微吸。但是，尽管其中一些方法可以最大程度地减少微量抽吸，但预防VAP的益处并不总是显而易见的。聚氨酯套入气管导管成功地减少了微量抽吸，但缺乏可证明VAP速率降低的高质量数据。与经典的桶形袖带相比，可以得出类似的结论。除了基于体外的证据外，还需要更多有关这些气管导管设计的临床数据来证明临床价值。多项研究确定了气管导管用于声门下分泌物引流的临床实用性，并通过荟萃分析得到证实。如果袖带充气不足，袖带设计的任何变化都将无法防止微量抽吸。至少一项经过精心设计的试验表明，连续进行袖带压监测和控制可降低VAP风险。在插管之前，对袖带的凝胶润滑会通过将高褶皱，低压袖带中的褶皱形成的通道塞入而暂时阻碍微抽吸。由于凝胶润滑的有益作用是暂时的，因此降低VAP风险的潜力可能并不重要。推荐最小呼气末正压至少为5 cmH2O，因为这样可以降低体外和体内微吸的风险。一项随机对照研究表明，使用PEEP（5-8 cmH2O）通气的患者VAP风险降低。关于床头高程，建议避免仰卧。在床头高程25-30°以上是否优选床头高程45°尚待证实。最后，不建议对接受肠内营养的机械通气患者进行胃残余体积的常规监测。

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