{"title":"吸痰前滴注生理盐水可减少插管和通气成人肺炎的发生率","authors":"Julie C. Reeve","doi":"10.1016/S0004-9514(09)70044-3","DOIUrl":null,"url":null,"abstract":"<div><h3>Question</h3><p>Does the instillation of normal saline before suctioning reduce the incidence of ventilator-associated pneumonia in intubated and ventilated adults?</p></div><div><h3>Design</h3><p>Randomised, controlled trial with blinded outcome assessment.</p></div><div><h3>Setting</h3><p>The medical/surgical intensive care unit of a tertiary oncology hospital in Brazil.</p></div><div><h3>Participants</h3><p>Adults expected to require at least 72 hours of mechanical ventilation via an endotracheal or tracheostomy tube. Previous ventilation within the past month and contraindications to bronchoscopy were exclusion criteria. Randomisation of 262 participants allotted 130 to the intervention group and 132 to a control group.</p></div><div><h3>Interventions</h3><p>Closed tracheal suction systems with heat and moisture exchangers were used with both groups and were changed regularly. All patients were nursed with backrest elevation to 45 degrees. Medical or nursing staff, who were blinded to group allocations, requested suctioning when any of the following occurred: visible or audible secretions, ventilator-patient asynchrony, and increased peak inspiratory pressures or decreased tidal volumes attributed to secretions. Respiratory therapists performed the suctioning according to a standardised procedure that included preoxygenation. The therapists instilled 8 mL of normal saline prior to suctioning in the intervention group only.</p></div><div><h3>Outcome measures</h3><p>The primary outcome was the incidence of ventilator-associated pneumonia (VAP). If VAP was suspected because of radiographic evidence plus either fever, leukocytosis, or purulent secretions, a bronchoscopy with standardised lavage was performed. VAP was considered confirmed if the bacterial density of the lavage fluid exceeded 1000 colony-forming units/mL. Secondary outcome measures included time to VAP, duration of mechanical ventilation, length of stay and mortality in the intensive care unit, unscheduled ventilation circuitry changes due to secretions, and number of suctions per day.</p></div><div><h3>Results</h3><p>All participants completed the study. Significantly fewer participants in the saline group developed VAP (14/130) than in the control group (31/132), relative risk reduction 0.54 (95% CI 0.18 to 0.74). This indicates that one patient will avoid developing VAP for every 8 patients in which saline instillation is used. Significant benefits of saline instillation were also seen in the incidence of VAP (9 vs 21 per 1000 days of mechanical ventilation, <em>p</em> = 0.01) and in the time to first VAP (<em>p</em> = 0.02). The groups did not differ significantly on the remaining secondary outcomes.</p></div><div><h3>Conclusion</h3><p>Instillation of normal saline before tracheal suctioning decreases the incidence of VAP in mechanically ventilated adults.</p></div>","PeriodicalId":50086,"journal":{"name":"Australian Journal of Physiotherapy","volume":"55 2","pages":"Page 136"},"PeriodicalIF":0.0000,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S0004-9514(09)70044-3","citationCount":"7","resultStr":"{\"title\":\"Instillation of normal saline before suctioning reduces the incidence of pneumonia in intubated and ventilated adults\",\"authors\":\"Julie C. 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All patients were nursed with backrest elevation to 45 degrees. Medical or nursing staff, who were blinded to group allocations, requested suctioning when any of the following occurred: visible or audible secretions, ventilator-patient asynchrony, and increased peak inspiratory pressures or decreased tidal volumes attributed to secretions. Respiratory therapists performed the suctioning according to a standardised procedure that included preoxygenation. The therapists instilled 8 mL of normal saline prior to suctioning in the intervention group only.</p></div><div><h3>Outcome measures</h3><p>The primary outcome was the incidence of ventilator-associated pneumonia (VAP). If VAP was suspected because of radiographic evidence plus either fever, leukocytosis, or purulent secretions, a bronchoscopy with standardised lavage was performed. VAP was considered confirmed if the bacterial density of the lavage fluid exceeded 1000 colony-forming units/mL. Secondary outcome measures included time to VAP, duration of mechanical ventilation, length of stay and mortality in the intensive care unit, unscheduled ventilation circuitry changes due to secretions, and number of suctions per day.</p></div><div><h3>Results</h3><p>All participants completed the study. Significantly fewer participants in the saline group developed VAP (14/130) than in the control group (31/132), relative risk reduction 0.54 (95% CI 0.18 to 0.74). This indicates that one patient will avoid developing VAP for every 8 patients in which saline instillation is used. Significant benefits of saline instillation were also seen in the incidence of VAP (9 vs 21 per 1000 days of mechanical ventilation, <em>p</em> = 0.01) and in the time to first VAP (<em>p</em> = 0.02). 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引用次数: 7
摘要
吸痰前滴注生理盐水是否能降低插管和通气成人呼吸机相关性肺炎的发生率?设计随机对照试验,采用盲法结局评估。巴西一家三级肿瘤医院的内科/外科重症监护病房。成人受试者预计需要通过气管内或气管造口管进行至少72小时的机械通气。排除标准为过去一个月内的通气史和支气管镜禁忌症。262名参与者的随机化,其中130人被分配到干预组,132人被分配到对照组。干预措施两组均采用带热交换器和湿气交换器的闭式气管吸引系统,并定期更换。所有患者均护理靠背抬高至45度。对分组分组不知情的医务人员或护理人员,当出现以下任何情况时要求进行吸痰:可见或可听到分泌物,呼吸机与患者不同步,由分泌物引起的呼吸峰值压力增加或潮气量减少。呼吸治疗师根据包括预充氧在内的标准化程序进行吸痰。仅干预组在抽吸前灌注生理盐水8ml。主要结局指标为呼吸机相关性肺炎(VAP)的发生率。如果由于影像学证据加上发热、白细胞增多或化脓性分泌物而怀疑VAP,则行支气管镜检查并进行标准化灌洗。如果灌洗液的细菌密度超过1000菌落形成单位/mL,则认为确认了VAP。次要结局指标包括到达VAP的时间、机械通气持续时间、在重症监护病房的住院时间和死亡率、因分泌物引起的计划外通气回路改变和每天吸痰次数。所有参与者均完成了研究。生理盐水组发生VAP的参与者(14/130)明显少于对照组(31/132),相对风险降低0.54 (95% CI 0.18 ~ 0.74)。这表明,每8例使用生理盐水的患者中,就有1例患者可以避免发生VAP。生理盐水灌注在VAP发生率(每1000天机械通气9 vs 21, p = 0.01)和到达第一次VAP的时间(p = 0.02)方面也有显著的益处。两组在其余次要结果上没有显著差异。结论气管吸痰前灌注生理盐水可降低成人机械通气患者VAP的发生率。
Instillation of normal saline before suctioning reduces the incidence of pneumonia in intubated and ventilated adults
Question
Does the instillation of normal saline before suctioning reduce the incidence of ventilator-associated pneumonia in intubated and ventilated adults?
Design
Randomised, controlled trial with blinded outcome assessment.
Setting
The medical/surgical intensive care unit of a tertiary oncology hospital in Brazil.
Participants
Adults expected to require at least 72 hours of mechanical ventilation via an endotracheal or tracheostomy tube. Previous ventilation within the past month and contraindications to bronchoscopy were exclusion criteria. Randomisation of 262 participants allotted 130 to the intervention group and 132 to a control group.
Interventions
Closed tracheal suction systems with heat and moisture exchangers were used with both groups and were changed regularly. All patients were nursed with backrest elevation to 45 degrees. Medical or nursing staff, who were blinded to group allocations, requested suctioning when any of the following occurred: visible or audible secretions, ventilator-patient asynchrony, and increased peak inspiratory pressures or decreased tidal volumes attributed to secretions. Respiratory therapists performed the suctioning according to a standardised procedure that included preoxygenation. The therapists instilled 8 mL of normal saline prior to suctioning in the intervention group only.
Outcome measures
The primary outcome was the incidence of ventilator-associated pneumonia (VAP). If VAP was suspected because of radiographic evidence plus either fever, leukocytosis, or purulent secretions, a bronchoscopy with standardised lavage was performed. VAP was considered confirmed if the bacterial density of the lavage fluid exceeded 1000 colony-forming units/mL. Secondary outcome measures included time to VAP, duration of mechanical ventilation, length of stay and mortality in the intensive care unit, unscheduled ventilation circuitry changes due to secretions, and number of suctions per day.
Results
All participants completed the study. Significantly fewer participants in the saline group developed VAP (14/130) than in the control group (31/132), relative risk reduction 0.54 (95% CI 0.18 to 0.74). This indicates that one patient will avoid developing VAP for every 8 patients in which saline instillation is used. Significant benefits of saline instillation were also seen in the incidence of VAP (9 vs 21 per 1000 days of mechanical ventilation, p = 0.01) and in the time to first VAP (p = 0.02). The groups did not differ significantly on the remaining secondary outcomes.
Conclusion
Instillation of normal saline before tracheal suctioning decreases the incidence of VAP in mechanically ventilated adults.