Canadian Respiratory Journal

Canadian Respiratory Journal / 2019 / Article

Comment on “Tapered Cuff versus Conventional Cuff for Ventilator-Associated Pneumonia in Ventilated Patients: A Meta-Analysis of Randomized Controlled Trials”

  • Bert Maertens | Stijn Blot |
  •  Article ID 2679513 |
  •  Published 07 Jul 2019

Response to: Comment on “Tapered Cuff versus Conventional Cuff for Ventilator-Associated Pneumonia in Ventilated Patients: A Meta-Analysis of Randomized Controlled Trials”

  • Xu An Huang | Wei Min Huang | ... | Zhang Qiang Ye |
  •  Article ID 1601785 |
  •  Published 13 Feb 2020
  • | View Article

Letter to the Editor | Open Access

Volume 2019 |Article ID 2679513 | 2 pages | https://doi.org/10.1155/2019/2679513

Comment on “Tapered Cuff versus Conventional Cuff for Ventilator-Associated Pneumonia in Ventilated Patients: A Meta-Analysis of Randomized Controlled Trials”

Academic Editor: Rocco Trisolini
Received27 Feb 2019
Accepted22 May 2019
Published07 Jul 2019

Despite progress in the field of infection prevention, avoiding ventilator-associated pneumonia (VAP) remains challenging. In this regard, we read with great interest the recently published paper by Huang et al. and would like to compliment the authors on this interesting meta-analysis [1].

Innovations in endotracheal tube design have emerged in an effort to avoid the microaspiration of contaminated oropharyngeal secretions, the main pathogenic mechanism for pneumonia development. Most of these innovations show promising results in laboratory settings, but often fail to translate this to clinically important benefits. While ultrathin polyurethane (PU) cuffs and taper-shaped cuffs are capable of reducing microaspiration, they fail to reduce pneumonia incidence in long-term ventilated patients [13]. We believe this is because a better sealing cuff leads to overabundant accumulation of subglottic secretions. In combination with short episodes of underinflation, this may lead to massive microaspiration, thereby nullifying any effect of temporarily improved sealing. Accordingly, both subglottic secretion drainage (SSD) and continuous cuff pressure regulation have shown to be effective in pneumonia prevention [4, 5].

The overall findings of Huang et al. are similar to those we found earlier [1, 3]. However, we were surprised to see data differed significantly between our review and the one by Huang et al. (Table 1). Two of these differences are due to a different search strategy. While our review included two studies without full publication [6, 7], Huang et al. did not search for unpublished work. The third difference is the data reported for the study by Philippart et al. [8]. They compared four groups; PU tapered, polyvinylchloride (PVC) tapered, PU cylindrical, and PVC cylindrical cuffs. We chose to combine both tapered groups and both cylindrical groups, while Huang et al. chose only to consider the PVC groups.


StudyHuang et al.Maertens et al.Reason for difference
TaperedStandardTaperedStandard
ETETETET

Bent et al.Not included037143Unpublished study
Mahmoodpoor et al., 2013632732632732No difference
Saito et al.Not included2310623106Unpublished study
Philippart et al.17129141293316238163Huang et al. only considered PVC cuffed tubes
Monsel et al.105285715521657Data error
Jailette et al.33162381633316238163No difference
Mahmoodpoor et al., 20173013846138Not includedSSD applied in tapered group

E: events; T: total; PVC: polyvinylchloride; SSD: subglottic secretion drainage.

We argue, however, that the last two differences are, in our opinion, due to erroneous comparisons by Huang et al. First of all, we believe the data reported for the study by Monsel et al. are wrong [9]. Huang et al. seem to have used the number of second postoperative pneumonia episodes, instead of the total number of microbiologically confirmed pneumonia episodes, as we did. Secondly, Huang et al. include a study by Mahmoodpoor et al. that was not included in our analysis [10]. We excluded this study because the two endotracheal tubes that were compared differed not only with regard to the shape of the cuff. In the tapered cuffed tubes, SSD was applied while this was not the case in the standard cuffed tubes. Since there is convincing evidence that SSD reduces VAP incidence, we believe that the difference observed in the study is largely attributable to SSD [5]. Not unexpectedly, this study is the only one of the five studies included in the meta-analysis of Huang et al. that found a significant difference in VAP incidence between both groups.

Nevertheless, we agree with the authors that there is no evidence that taper-shaped cuffs provide any benefit on clinically important outcomes. However, as highlighted above, we believe this might be due to accumulation of secretions above a better sealing cuff. The effect of taper-shaped cuffs vs. standard cuffs with concomitant use of SSD and/or continuous cuff pressure regulation remains largely unexplored.

Conflicts of Interest

On behalf of all authors, the corresponding author states that there are no ethical or financial conflicts of interest.

References

  1. W. M. Huang, X. A. Huang, Y. P. Du et al., “Tapered cuff versus conventional cuff for ventilator-associated pneumonia in ventilated patients: a meta-analysis of randomized controlled trials,” Canadian Respiratory Journal, vol. 2019, Article ID 7876417, 7 pages, 2019. View at: Publisher Site | Google Scholar
  2. S. I. Blot, J. Rello, and D. Koulenti, “The value of polyurethane-cuffed endotracheal tubes to reduce microaspiration and intubation-related pneumonia: a systematic review of laboratory and clinical studies,” Critical Care (London, England), vol. 20, no. 1, p. 203, 2016. View at: Publisher Site | Google Scholar
  3. B. Maertens, K. Blot, and S. Blot, “Prevention of ventilator-associated and early postoperative pneumonia through tapered endotracheal tube cuffs,” Critical Care Medicine, vol. 46, no. 2, pp. 316–323, 2018. View at: Publisher Site | Google Scholar
  4. S. Nseir, L. Lorente, M. Ferrer, A. Rouze, O. Gonzalez, and G. L. Bassi, “Continuous control of tracheal cuff pressure for VAP prevention: a collaborative meta-analysis of individual participant data,” Annals of Intensive Care, vol. 5, no. 1, p. 43, 2015. View at: Publisher Site | Google Scholar
  5. D. A. Caroff, L. Li, J. Muscedere, and M. Klompas, “Subglottic secretion drainage and objective outcomes: a systematic review and meta-analysis,” Critical Care Medicine, vol. 44, no. 4, pp. 830–840, 2016. View at: Publisher Site | Google Scholar
  6. S. Galwankar, M. Vyas, D. Desai, and Z. F. Udwadia, “Hepatic sarcoidosis responding to chloroquine as steroid-sparing drug,” Indian Journal of Gastroenterology, vol. 18, no. 4, pp. 177-178, 1999. View at: Google Scholar
  7. N. Saito, T. Yagi, Y. Hara, H. Matsumoto, and K. Mashiko, “Endotracheal tube with tapered-type cuff for preventing ventilator-associated pneumonia: a randomized clinical trial,” Critical Care, vol. 17, p. P153, 2013. View at: Publisher Site | Google Scholar
  8. F. Philippart, S. Gaudry, L. Quinquis et al., “Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients,” American Journal of Respiratory and Critical Care Medicine, vol. 191, no. 6, pp. 637–645, 2015. View at: Publisher Site | Google Scholar
  9. A. Monsel, Q. Lu, M. Le Corre et al., “Tapered-cuff endotracheal tube does not prevent early postoperative pneumonia compared with spherical-cuff endotracheal tube after major vascular surgery,” Anesthesiology, vol. 124, no. 5, pp. 1041–1052, 2016. View at: Publisher Site | Google Scholar
  10. A. Mahmoodpoor, H. Hamishehkar, M. Hamidi et al., “A prospective randomized trial of tapered-cuff endotracheal tubes with intermittent subglottic suctioning in preventing ventilator-associated pneumonia in critically ill patients,” Journal of Critical Care, vol. 38, pp. 152–156, 2017. View at: Publisher Site | Google Scholar

Copyright © 2019 Bert Maertens and Stijn Blot. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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