Conclusions - Stellenbosch University



PREVENTION AND MANAGEMENT OF VAP IN INTUBATED AND VENTILATED PATIENTS

Review question: Is CPT effective in the prevention and management of ventilator associated pneumonia (VAP) in intubated and ventilated patients compared with no intervention?

Following a systematic review of the literature; critical appraisal of identified studies; the following conclusions were reached:

SEARCH RESULTS

• Six studies were included in this review. This includes three experimental studies (Ntoumenopoulos et al 1998; Ntoumenopoulos et al 2002; Choi et al 2005); one clinical guideline (Dodek et al 2004) and two systematic reviews (Gastmeier et al 2007; Von Bergh et al 2006).

• Five studies into strategies to prevent VAP were pubished (Ntoumenopoulos et al 1998; Ntoumenopoulos et al 2002; Dodek et al 2004; Gastmeier et al 2007; Von Bergh et al 2006) and one study (Choi et al 2005) investigated the effect of CPT techniques on the pulmonary dynamics in patients diagnosed with VAP.

• The preventative strategies include patient positioning; optimal suction system and routine CPT.

Experimental studies

• Two experimental studies (RCT) evaluated the effect of CPT techniques in the prevention of VAP (Ntoumenopoulos et al 1998; Ntoumenopoulos et al 2002) and one crossover RCT was done to investigate the effect of these techniques on the respiratory mechanics in patients already diagnosed with VAP (Choi et al 2005).

• The internal validity of the studies is compromised, scoring between 3 and 6/11 on PEDRO scale (refer to table 1).

Clinical guideline

• One evidenced based clinical guideline for the prevention of VAP in intubated and ventilated patients was identified (Dodek et al 2004).

• The clinical guideline developed by Dodek et al (2004) scored above 70% in all the domains of the AGREE instrument (refer to table 3 for domain scores).

Systematic Review

• Three systematic reviews were included in this review (Gastmeier et al 2007; Von Bergh et al 2006; Subraiana et al 2007).

• Gastmeier et al (2007) review was an update of the Dodek et al (2004) guideline evaluating multidisciplinary strategies to prevent VAP. Even though a number of primary research papers were published between 2004 and 2007 – they concluded that no additions could be made to the 2004 guideline.

• Von Bergh et al (2006) and Subriana et al (2008) reviewed the evidence to decide between closed and open suction systems in the prevention of VAP.

SUMMARY OF EVIDENCE

• It remains unclear whether the routine twice daily application of a CPT package will prevent the development of VAP (Ntoumenopolous et al 1998; Ntoumenopoulos et al 2002; Dodek et al 2004 )

• CPT techniques including MHI and suctioning into the management of patients diagnosed with VAP may improve lung compliance (Choi et al 2005).

• When infiltrates are visible on CxR a CPT package including gravity assisted positioning; MHI and suction does not have adverse effects and could prevent the progression of pathology (Ntoumenopoulos et al 2002 and Ntoumenopoulos et al 1998).

Table 1 Summary of experimental studies

|Experimental |Internal |Sample |Population |Intervention and comparison |Study structure |Outcome measured |

|Studies |validity |size | | | | |

| |Pedro | | | | | |

|Ntoumenopoulos et|4 |46 |Intubated and ventilated for at |Gravity assisted position; |RCT |LOS; mortality; TOV; |

|al 2002 | | |least 48 hours |shakings and suction compared | |Incidence of VAP (CPIS diagnosed)|

| | | | |to “sham therapy” (occasional | | |

| | | | |musculo-skeletal) | | |

|Choi et al 2005 |3 |15 |Intubated and ventilated patients |MHI and suction compared to |Crossover RCT |Static pulmonary compliance and |

| | | |diagnosed with VAP |suction alone | |inspiratory resistance |

• Patients must be nursed in semi recumbent position with the goal of 45O head up position (Dodek et al 2004; Gastmeier et al 2007).

• There is no difference in open and closed suction systems in the prevention of VAP, but open systems could be more cost effective (Von Bergh et al 2006; Subriana et al 2008).

Table 2 Summary of reviews / metanalysis

|Review |AMSTAR |Studies included |Population |Intervention and |Outcome measured |Conclusion |

| |Score | | |comparison | | |

|Gastmeier et al |5 |15 RCT’s and 7 meta |Adult intubated |Variety of |Incidence of VAP |Despite a number of studies |

|2007 | |analyses |population |preventative | |published after 2004 the |

| | | | |strategies | |recommendations made by Dodek et |

| | | | | | |al 2004 remain |

|Subriana et al 2008|11 |11 RCT’s |Adult intubated |Open suction system |Incidence of VAP; |suctioning with either closed or |

| | | |population |compared to closed |LOS; mortality |open tracheal suction systems did |

| | | | |suction system | |not have an effect on the risk |

| | | | | | |of ventilator-associated pneumonia|

| | | | | | |or mortality |

Table 3: Levels of guideline recommendations Dodek et al 2004

|Strategy |Recommendation |Motivation |

|Prophylactic physiotherapy for the |We make no recommendation |On the basis of evidence from one trial,chest physiotherapy may be |

|prevention of VAP | |associated with decreased incidence of VAP. However, methodologic |

| | |limitations of this trial and the lack of feasibility of universal |

| | |application preclude widespread use of this intervention. |

|Routine semi-recumbent positioning |We recommend the use of semi-recumbent |On the basis of evidence from one trial with minimal methodological |

| |positioning, with a goal of 45 degrees, in |limitations, we conclude that semi-recumbent positioning (caring for |

| |patients without contraindications. |patients positioned at 45 degrees from horizontal) is associated with |

| | |decreased incidence of VAP. Semi-recumbent positioning may be unsafe for |

| | |some patients but is a feasible and low-cost intervention. |

SUMMARY OF THE QUALITY OF THE EVIDENCE

• Two studies investigated the effect of a routine twice daily physiotherapy package (position; suction; MHI or vibrations) on the incidence of VAP (Ntoumenopolous et al 1998; Ntoumenopolous et al 2002) with conflicting results. The physiotherapeutic package of care provided in two RCT’s (Ntoumenopolous et al 1998; Ntoumenopolous et al 2002) did not affect TOV; ICU LOS or mortality. It showed a tendency to reduce the incidence of VAP (diagnosed by CPIS) in one study. The quality of evidence is downgraded to low due to imprecision of sample and poor methodological quality (refer to table 2). Furthermore, patients only entered into the study after two days of intubation and positioned on a side to drain a segment where there was already radiographic evidence of infiltrates.

Table 4 Factors considered in determining the quality of the evidence for RCT’s

|Experimental |Risk of bias | |Heterogeneity | |

|Studies | |Directness of evidence | |Precision |

| |Concealed allocation |LTFO |ITT |Intervention |Sample |Publication |Data |

| | |Lost to follow up | |investigated |investigated |Bias | |

• The quality of evidence available for chosing between an OSS or CSS remains high as it is provided by two well conducted systematic reviews reaching the same conclusion (Van Berg et al 2006 and Subriana et al 2008) refer to table 6.

• Only one study investigated the immediate effect of MHI and suction on the pulmonary dynamics of patients diagnosed with VAP (Choi et al 2005) and reported a significant improvement in pulmonary compliance compared to baseline. Quality of the evidence was downgraded to low due to methodological quality and imprecision (refer to table 5).

NOTE In the study by Ntoumenopelous et al (2002) subjects only entered into the study after 48 hours of intubation and with infiltrates visible on CxR. The mean CPIS score was measured daily for the duration of ICU stay and diagnosed with VAP combining clinical diagnosis and CPIS score. Because the provision of physiotherapy to patients diagnosed with VAP is regarded as a standard of care; and no studies to date have evaluated the optimal package of care it is recommended that the package of care investigated by Ntoumenopolous et al (2002) to prevent VAP be used as the basis for the physiotherapeutic management of patients where VAP has been diagnosed. This package also includes the techniques (MHI and suction) investigated by Choi et al (2005).

Table 6 Quality of evidence from systematic review

|Review |Methodological quality | |Heterogeneity | |

| |assessed |Directness of evidence | |Precision |

| | |Intervention |Sample investigated |Publication Bias |Data |

| | |investigated | | |Sample |

|Gastmeier et al |None described |yes |yes |No did not assess |Did not assess |

|2007 | | | | | |

|Subriana et al 2008|yes |yes |yes |No (p=0.26) |Pooled RR 0.88; (95% CI 0.70 to 1.12) |

Table 7 Factors considered in determining the quality of the evidence for the crossover design study

|Experimental |Risk of bias | |Heterogeneity | |

|Studies | |Directness of evidence | |Precision |

|Study design |Washout period |Sample selected |Intervention investigated |Sample investigated |Publication Bias |Data |Sample | |Choi et al 2005 |Yes: Appropriate |Yes: Baseline comparisons not significantly different |No: did not include APACHE; TOV |Yes |Yes |NA |Insufficient data to calculate mean difference |No | |

-----------------------

RECOMMENDATIONS

Preventative strategies Post your comments on the website

Routine twice daily CPT physiotherapy to all patients in ICU to prevent VAP is NOT RECOMMENDED at this time

Motivation: Two studies investigated the effect of a routine twice daily physiotherapy package (position; suction; MHI or vibrations) on the incidence of VAP (Ntoumenopolous et al 1998; Ntoumenopolous et al 2002) with conflicting results. The physiotherapeutic package of care provided in two RCT’s (Ntoumenopolous et al 1998; Ntoumenopolous et al 2002) did not affect TOV; ICU LOS or mortality. It showed a tendency to reduce the incidence of VAP (diagnosed by CPIS) in one study. The quality of evidence is downgraded to low due to imprecision of sample and poor methodological quality (refer to table 2). Furthermore, patients only entered into the study after two days of intubation and positioned on a side to drain a segment where there was already radiographic evidence of infiltrates (refer to management)

Recommendation 1

• All intubated patients (that do not present with contra indications) should be nursed in a semi-recumbent position with the goal of 45O head up to prevent the development of VAP.

Strong recommendation This positioning resulted in a decrease in the incidence of VAP in one clinical guideline (Dodek et al 2004) and one systematc review (Gastmeier et al (2007). The cost and burden of implementing a basic nursing position for all intubated patients in ICU is very low compared to the possibility of preventing the development of VAP

based on moderate quality evidence: One well developed clinical guideline (Dodek et al 2004) scoring above 75 for all the domains of the AGREE instrument and a systematic review updating the evidence (Gastmeier et al 2007). Evidence is downgraded due to imprecision of data

Recommendation 2

• No suction system (open or closed) is superior in the prevention of VAP in intubated patients. The choice of which system to use must be based on availability.

Strong recommendation None of the systems (OSS or CSS) reported a decrease in the incidence of VAP. Intubated patients are suctioned regularly in ICU and claims have been made to the effectiveness of CSS over OSS. It is therefore important to recognize that no system is superior

based on high quality evidence from one meta analysis evaluating 9 RCT’s.

Post your comments

Post your comments

Post your comments

Post your comments

Post your comments

Post your comments

Post your comments

Management strategy

Recommendation 3

• When infiltrates are visible on CxR a CPT package including a gravity assisted drainage position; MHI and suctioning should be initiated with a frequency of two treatment sessions per day.

Weak recommendation significant improvement in static lung compliance and inspiratory resistance was documented in one randomized cross over design study (Choi et al 2005). Although significant improvement was documented in the respiratory mechanics the impact of these changes on long term outcome is not clear.

based on low quality evidence: one randomized crossover RCT (Choi et al 2005). Evidence was downgraded because of methodological quality and imprecision.

NOTE In the study by Ntoumenopelous et al (2002) subjects only entered into the study after 48 hours of intubation and with infiltrates visible on CxR. The mean CPIS score was measured daily for the duration of ICU stay and the diagnosis was based on a combination of clinical diagnosis and CPIS score. Because the provision of physiotherapy to patients diagnosed with VAP is regarded as a standard of care; and no studies to date have evaluated the optimal package of care it is recommended that the package of care investigated by Ntoumenopolous et al (2002) to prevent VAP be used as the basis for the physiotherapeutic management of patients where VAP has been diagnosed. This package also includes the techniques (MHI and suction) investigated by Choi et al (2005).

Post your comments

Post your comments

Post your comments

Post your comments

Post your comments

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download