The Impact of Hospital-Wide Use of a Tapered-Cuff Endotracheal Tube on the Incidence of Ventilator-Associated Pneumonia

Abstract

BACKGROUND: Aspiration of colonized oropharyngeal secretions is a major factor in the pathogenesis of ventilator-associated pneumonia (VAP). A tapered-cuff endotracheal tube (ETT) has been demonstrated to reduce aspiration around the cuff. Whether these properties are efficacious in reducing VAP is not known. METHODS: This 2-period, investigator-initiated observational study was designed to assess the efficacy of a tapered-cuff ETT to reduce the VAP rate. All intubated, mechanically ventilated patients over the age of 18 were included. During the baseline period a standard, barrel-shaped-cuff ETT (Mallinckrodt Hi-Lo) was used. All ETTs throughout the hospital were then replaced with a tapered-cuff ETT (TaperGuard). The primary outcome variable was the incidence of VAP per 1,000 ventilator days. RESULTS: We included 2,849 subjects, encompassing 15,250 ventilator days. The mean ؎ SD monthly VAP rate was 3.29 ؎ 1.79/ 1,000 ventilator days in the standard-cuff group and 2.77 ؎ 2.00/1,000 ventilator days in the tapered-cuff group (P ‫؍‬ .65). While adherence to the VAP prevention bundle was high throughout the study, bundle adherence was significantly higher during the standard-cuff period (96.5 ؎ 2.7%) than in the tapered-cuff period (90.3 ؎ 3.5%, P ‫؍‬ .01). CONCLUSIONS: In the setting of a VAP rate very near the average of ICUs in the United States, and where there was high adherence to a VAP prevention bundle, the use of a tapered-cuff ETT was not associated with a reduction in the VAP rate.

Bacteriological Study of Ventilator-Associated Pneumonia in a Tertiary Care Hospital.

“…The rate of VAP obtained in our study is 2.06 cases per 1000 ventilator days similar to a study conducted by Bowton DL et al 23 However, a study by Panwar et al 24 reported the VAP rate as 26 per 1000 ventilator days. …”

Randomized Intubation with Polyurethane or Conical Cuffs to Prevent Pneumonia in Ventilated Patients

“…These hypotheses were confirmed in a bench (10) and a pilot study (16). Whether this improved sealing translates in to VAP reduction remains unanswered, since studies have yielded conflicting results: (6,11,28,29).…”

Endotracheal Tubes: Old and NewDiscussion

“…Dye was injected above the cuff, and fluid leakage was assessed by bronchoscopy periodically for up to 2 h. While dye in the trachea was seen in 20% of subjects with the cylindrical cuff, none was seen in those with the tapered cuff. Bowton et al 128 reported the impact of a hospital-wide conversion from a standard cylindrical PVC-cuffed ETT to a tapered PVC-cuffed ETT. They reported no difference in VAP rate during either 6-month study period: mean monthly rate of 3.3 Ϯ 1.8/1,000 ventilator days versus 2.8 ϩ 2.0/1,000 ventilator days for the cylindrical and tapered cuff groups, respectively, although the authors noted that their historic VAP rate was 5.8/1,000 ventilator days.…”

“…They reported no difference in VAP rate during either 6-month study period: mean monthly rate of 3.3 Ϯ 1.8/1,000 ventilator days versus 2.8 ϩ 2.0/1,000 ventilator days for the cylindrical and tapered cuff groups, respectively, although the authors noted that their historic VAP rate was 5.8/1,000 ventilator days. 128 A novel cuff design recently reported by Hwang et al 129 involves attaching a second PVC cuff to a standard ETT separated by 5 mm (Fig. 11).…”