Date Published: May 23, 2019
Publisher: Public Library of Science
Author(s): Ana Catalina Hernandez Padilla, Timothée Trampont, Thomas Lafon, Thomas Daix, Dominique Cailloce, Olivier Barraud, François Dalmay, Philippe Vignon, Bruno François, Andrea Coppadoro.
More than half of patients under mechanical ventilation in the intensive care unit (ICU) are field-intubated, which is a known risk factor for ventilator associated pneumonia (VAP). We assessed whether field endobronchial intubation (EBI) is associated with the development of subsequent VAP during the ICU stay. This retrospective, nested case-control study was conducted in a cohort of field-intubated patients admitted to an ICU of a teaching hospital during a three-year period. Cases were defined as field-intubated patients with EBI and controls corresponded to field-intubated patients with proper position of the tracheal tube on admission chest X-ray. Primary endpoint was the development of early VAP. Secondary endpoints included the development of early ventilator associated tracheo-bronchitis, late VAP, duration of mechanical ventilation, length of stay and mortality in the ICU. A total of 145 patients were studied (mean age: 54 ± 19 years; men: 74%). Reasons for field intubation were predominantly multiple trauma (49%) and cardiorespiratory arrest (38%). EBI was identified in 33 patients (23%). Fifty-three patients (37%) developed early or late VAP. EBI after field intubation was associated with a nearly two-fold increase of early VAP, though not statistically significant (30% vs. 17%: p = 0.09). No statistically significant difference was found regarding secondary outcomes. The present study suggests that inadvertent prehospital EBI could be associated with a higher incidence of early-onset VAP. Larger studies are required to confirm this hypothesis. Whether strategies aimed at decreasing the incidence and duration of EBI could reduce the incidence of subsequent VAP remains to be determined.
Ventilator associated pneumonia (VAP) is the most frequent infectious complication in the intensive care unit (ICU) which is associated with increased mortality, ICU length of stay and hospital costs [1–4]. Field intubation has been reported as an independent risk factor for VAP [1,5–7]. Nevertheless, it is often necessary and accounts for 70 to 77% of tracheal intubation in ventilated trauma patients admitted to the ICU [5,8].
During the study period, 398 patients underwent a field intubation and were subsequently admitted to our medical-surgical ICU. A total of 253 patients were excluded because they were early extubated (n = 104), died within the first two days following hospital admission (n = 90), had an underlying lung disease precluding accurate chest X-ray interpretation (n = 8), or for any other predefined reason (n = 51) (Fig 1). Finally, 145 patients were studied (median age: 56 IQR [41–69] years; 107 (74%) men; SAPS 2: 60 [45–67]). Reasons for field intubation were initial cardiorespiratory arrest (38%), severe polytrauma (49%), coma (11%), and acute respiratory failure (2%). Among patients intubated in the field for a cardiac arrest, 73% underwent targeted therapeutic hypothermia. Right-sided EBI was diagnosed in 33 patients (23%) (Fig 2), while no left-sided EBI was identified. Median duration of EBI was 143 [78–185] min.
The present study showed that patients intubated in the field who present to the hospital with endobronchial intubation (EBI) have a trend towards an increase of early ventilator associated pneumonia (VAP) and both early VAP and ventilator associated tracheo-bronchitis (VAT) when compared to those with a proper positioning of the tube in the trachea, even though the difference fails to reach statistical significance presumably due to a lack of power.