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【medical-news】银包被的气管内插管可降低呼吸机
"VAP causes substantial morbidity," write Marin H. Kollef, MD, from the Washington University School of Medicine in St. Louis, Missouri, and colleagues from the North American Silver-Coated Endotracheal Tube Investigation Group. "A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation."
The goal of this prospective, single-blind study conducted in 54 centers in North America was to evaluate whether use of a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP.
Of 9417 adult patients aged 18 years or older who were screened between 2002 and 2006, a total of 2003 patients who were expected to need mechanical ventilation for at least 24 hours were randomly assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes. These tubes were similar except that the experimental tube had a silver coating.
The main endpoint was incidence of VAP, diagnosed from quantitative bronchoalveolar lavage fluid culture with at least 104 colony-forming units/mL in patients intubated for at least 24 hours. Secondary endpoints were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality rates, and adverse events.
Rates of microbiologically confirmed VAP in patients intubated for at least 24 hours were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4% - 6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7% - 9.7%; P = .03) in the group receiving the uncoated tube (relative risk reduction, 35.9%; 95% CI, 3.6% - 69.0%).
Rates of microbiologically confirmed VAP in all intubated patients were 3.8% (37/968; 95% CI, 2.7% - 5.2%) in the experimental group and 5.8% (56/964; 95% CI, 4.4% - 7.5%; P = .04) in the control group (relative risk reduction, 34.2%; 95% CI, 1.2% - 67.9%).
Use of the silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005), but there were no statistically significant between-group differences in durations of intubation, intensive care unit stay, and hospital stay. Mortality rates and frequency and severity of adverse events were also similar in both groups.
"Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube," the study authors write. "The silver-coated endotracheal tube appears to offer a unique approach because it is the first intervention that becomes user-independent after intubation, requiring no further action by the clinician."
Limitations of this study include single blinding rather than double blinding; use of a small, fixed block size stratified by center; other factors possibly contributing to between-group differences in VAP rates; study protocol not standardizing prevention strategies; and a protective effect of higher severity-of-illness scores against development of VAP.
In an accompanying editorial, Jean Chastre, MD, from Institut de Cardiologie, Groupe Hospitalier Pitié-Salpê trière in Paris, France, discusses the study limitations.
"Important uncertainties exist regarding the exact benefit of silver-coated endotracheal tubes," Dr. Chastre writes. "Consequently, silver coated tubes should not be viewed as the definitive answer for VAP prevention, and, until additional data confirm the clinical effectiveness and cost benefit of these devices, their use should be restricted to high-risk patients treated in ICUs [intensive care units] with benchmark value-based infection rates that remain above institutional goals despite implementation of a comprehensive strategy of usual preventive measures to prevent VAP."
CR Bard Inc supported this study and provided grant support to all of the study authors. Some of the study authors have disclosed various financial relationships with Kimberly Clark, Elan, Merck, Pfizer, Bayer, GlaxoSmithKline, Boehringer Ingelheim, KCI, sanofi-aventis, Johnson & Johnson, Easi, Hospira, Nomir Medical Technologies, Arpida, Cubist, Elan, Ortho-McNeil, Sanofi Pasteur, Wyeth, Bayer-Nektar, Nestle Clinical Nutrition, Lilly, Corbett Accel Healthcare, National Institutes of Health, Novartis, and/or Maquet. Dr. Chastre has received consulting and lecture fees from Pfizer, Brahms, Wyeth, Johnson & Johnson, Bayer-Nektar, and Arpida.
JAMA. 2008.300:805-813, 842-844. 本人已认领该文编译，48小时后若未提交译文，请其他战友自由认领。 August 19, 2008 — Use of a silver-coated endotracheal tube significantly reduces the incidence of microbiologically confirmed ventilator-associated pneumonia (VAP), according to the results of a large, randomized, multicenter study reported in the August 20 issue of the Journal of the American Medical Association.
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作者:admin@医学,生命科学 2011-01-25 05:14
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