Journal of Critical Care 38 (2017) 152–156

Contents lists available at ScienceDirect

Journal of Critical Care

journal homepage: www.jccjournal.org

A prospective randomized trial of tapered-cuff endotracheal tubes with

intermittent subglottic suctioning in preventing ventilator-associated
pneumonia in critically ill patients☆,☆☆,★
Ata Mahmoodpoor, MD, FCCM a, Hadi Hamishehkar, PhD b, Masoud Hamidi, MD a, Kamran Shadvar, MD, FCCM a,
Sarvin Sanaie, MD c, Samad EJ Golzari, MD a, Zahid Hussain Khan, MD d, Nader D. Nader, MD, PhD, FACC, FCCP e,⁎
a
Department of Anesthesiology and Critical Care Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
b
Department of Clinical Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
c
Tuberculosis and Lung Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
d
Department of Anesthesiology and Critical Care Medicine, Tehran University of Medical Sciences, Tehran, Iran
e
Department of Anesthesiology, 252 Farber Hall, State University of New York at Buffalo, 3435 Main St, Buffalo, NY 14214

a r t i c l e i n f o a b s t r a c t

Keywords: Background: Endotracheal tube placement is necessary for the control of the airway in patients who are mechan-
TaperGuard endotracheal tubes ically ventilated. However, prolonged duration of endotracheal tube placement contributes to the development
Ventilator-associated pneumonia of ventilator-associated pneumonias (VAPs). The aim of this study was to evaluate whether subglottic suctioning
Intensive care units using TaperGuard EVAC tubes was effective in decreasing the frequency of VAP.
Methods: A total of 276 mechanically ventilated patients for more than 72 hours were randomly assigned to
group E (EVAC tube) and group C (conventional tube). All patients received routine care including VAP preven-
tion measures during their intensive care unit stay. In group E, subglottic suctioning was performed every 6
hours. Outcome variables included incidence VAP, intensive care unit length of stay, and mortality.
Results: Frequency of intraluminal suction, mechanical ventilation–free days, reintubation, the ratio of arterial
oxygen partial pressure to fractional inspired oxygen and mortality rate were similar between the 2
groups (P N .05). The mean cuff pressure in group E was significantly less than that in group C (P b .001). Venti-
lator-associated pneumonia was significantly less in group E compared with group C (P = .015).
Conclusion: The use of intermittent subglottic secretion suctioning was associated with a significant decrease in
the incidence of the VAP in critically ill patients. However, larger multicenter trials are required to arrive at a con-
crete decision on routine usage of TaperGuard tubes in critical care settings.
Published by Elsevier Inc.

1. Introduction
Ventilator-associated pneumonia (VAP) is the serious common nos-
ocomial infection in the intensive care unit (ICU) which is associated
with prolonged hospitalization, increased health care cost, and high
mortality rate [1,2]. During the past few decades, numerous studies
☆ Trial registration: ACTRN12611000038998
☆☆ Presented in part at the IV-NWAC 2013 World Anesthesia Convention; Bangkok,
Thailand; April 23-27, 2013.
★ Disclosures for financial support: Funds were available from the office of the Associate
Dean for Medical Research, Tabriz University of Medical Sciences.
⁎ Corresponding author. Tel.: +1 716 345 7909.
E-mail addresses: amahmoodpoor@yahoo.com (A. Mahmoodpoor), hamishehkar@
gmail.com (H. Hamishehkar), masoodhamidi59@yahoo.com (M. Hamidi), k_shadvar@
yahoo.com (K. Shadvar), sarvin_so2000@yahoo.com (S. Sanaie), dr.golzari@hotmail.com
(S.E.J. Golzari), Khanzh51@yahoo.com (Z.H. Khan), nnader@buffalo.edu, nadernd@
gmail.com (N.D. Nader).
have focused on the central role of endotracheal tubes (ETTs) in the
pathogenesis of VAP [3]. Endotracheal intubation impairs normal
mucociliary clearance and cough reflex which in turn leads to mucus
plug formation, atelectasis, and finally pneumonia. Ventilator-associat-
ed pneumonia prevention necessitates aspiration of subglottic secre-
tions as they play a major role in the pathogenesis of VAP [4-7].
Conventional tubes permit only intermittent suction of intraluminal
secretions without having any effect on subglottic secretions, whereas
newer tubes allow for continuous aspiration of subglottic secretions
(CASSs) [8].
TaperGuard, MallinckrodtTM, Boulder, CO EVAC ETTs are equipped
with a dorsal suction catheter for subglottic secretion drainage. This suc-
tion lumen has 2 ports: an external port for connection to suction and a
subglottic port located 10 mm above the cuff [9]. Some trials have
shown that Evac tubes could be used as a VAP preventive strategy
(VAP bundle) in patients who are placed under mechanical ventilation
[10-12], whereas some others have failed to demonstrate the beneficial

http://dx.doi.org/10.1016/j.jcrc.2016.11.007
0883-9441/Published by Elsevier Inc.
 A. Mahmoodpoor et al. / Journal of Critical Care 38 (2017) 152–156 153

effects of Evac tubes in preventing VAP [2,7]. Microchannel formation

within the inflated cuff, which is the most likely venue for the bronchial
transmission of bacterial pathogens and secondary development of VAP,
is halted within the folds of the cuff of the tapered tubes. Evac tubes
with polyurethane cuff have an ultra-thin cuff membrane (thickness
of 7 μm) compared with the cuff membrane of conventional ETT (thick-
ness of N50 μm). The elliptical tube cuff is more effective than old round
cuffs in preventing subglottic fluid leakage across the tube cuff through
the folding and channel formation. TaperGuard tubes have been de-
signed to prevent folding within the cuff, and therefore to decrease
fluid passage through the formed channels [13-15]. Compared with tra-
ditional cuffed tubes, TaperGuard tubes require lower cuff pressures to
maintain adequate sealing through more uniform pressure distribution,
thereby reducing microaspiration by as much as 90% while exerting 29%
less pressure on the trachea [16]. Because the heterogeneity among crit-
ically ill patients and small sample size in the trials, a final conclusion re-
garding the efficacy of TaperGuard tubes in VAP prevention remains a
matter of controversy. Because of the lack consensus in this area, the
use of these tubes in critically ill patients has not earned popularity. In
this trial, we determined the effect of tapered-cuff ETT with a capability
of subglottic suctioning on the rate of VAP occurrence in critically ill
patients.

2. Patients and methods

The study design, protocol, and the informed consent process were
reviewed for its merit by the institutional review board of Tabriz
University of Medical Sciences. The study conformed to the research
ethics and good clinical research guidelines published by the National
Institute of Health. The study was registered with Australian New
Zealand Clinical Trials Registry at http://www.anzctr.org.au/ (Trial ID:
Fig. 1. Study flow diagram.
ACTRN12611000038998).

2.1. Sample size determination and power analysis

Based on previous studies [17,18], reporting an occurrence rate of 9%
to 27% for VAP in intubated patients, a sample size of 138 patients was
calculated for each study arm (with α = .05, power = 80%, and true fail-
ure rate for experimental subjects = 0.135).
2.2. Inclusion and exclusion criteria and patient randomization
Inclusion criteria included patients aged between 18 and 80 years
requiring mechanical ventilation for more than 72 hours with place-
ment of an ETT from January 2011 to January 2013. Exclusion criteria
were patients transferred from other hospitals, urgent intubation in
wards other than ICU, history of mechanical ventilation, pregnancy,
HIV, immunosuppression, leukopenia, patient refusal, and acute respi-
ratory distress syndrome. Patients who were receiving antibiotics at
the time of intubation were excluded from a study designed to assess
the efficacy of a preventive intervention. All patients received 5 cm
H2O positive end-expiratory pressure (PEEP) to eliminate the effect of
PEEP on VAP. If a patient needed higher PEEPs, he/she was excluded
from the study, as PEEP could result in a better sealing capacity through-
out the ventilation cycle and as such reduce microaspiration [19-22].
After initial screening for eligibility, 276 patients were enrolled in
the study after an informed consent form was signed by their next of
kin or health care proxy (Fig. 1). Patients were randomized (block ran-
domization) into 2 groups, each comprising 138 patients. Randomiza-
tion was performed with a Web-based software. In group E, patients
were intubated with TaperGuard tubes, and in group C, conventional
high-volume low-pressure ETTs were used. Attending anesthesiologists
who were experienced in placement of ETTs performed the intubation.
Male patients were intubated with an 8.0- to 8.5-mm internal diameter
ETT, and female patients were intubated with a 7.0- to 7.5-mm internal
diameter ETT. Tubes were changed only when there was a need for
exchange like obstruction or cuff perforation. Cuff pressure was main-
tained between 20 and 30 cm H2O and measured every 6 hours in all pa-
tients in each group. Additional to those scheduled around the clock,
tracheal suctioning and pulmonary toilet were performed as indicated.
Because there were reports of partial or complete obstruction of the
suctioning port, we applied intermittent suctioning with a negative
pressure of 100 mm Hg to maintain its patency [23]. In group E,
subglottic suctioning was performed every 6 hours via the suction
port. All patients underwent preoxygenation before suctioning and du-
ration of each suction was kept under 15 seconds. After cuff pressure
checking in group E, 5 mL distilled sterile water was instilled through
the subglottic lumen to maintain its patency. If mucus flow stopped dur-
ing subglottic suctioning with a sudden increase of the negative pres-
sure in the proximal port of the suction suggesting a probable
occlusion, the suction was disconnected and 10 mL sterile distilled
water was instilled to reopen the lumen. Then, routine suction was per-
formed similar to control group based on patients' need.
Patients received 25 kcal/kg (ideal body weight) of standard formula
with 1 kcal/mL via dubhoff tubes. Sedation levels of all patients were
monitored and kept between 0 and −1 scores of Richmond Agitation
Sedation Scale. Demographic characteristics and underlying diseases
for all patients were recorded. Acute Physiology and Chronic Health
Evaluation II (APACHE II) score, arterial oxygen partial pressure to
fractional inspired oxygen (PaO2/FIO2) ratio, length of hospital and ICU
stay, duration of mechanical ventilation, tracheostomy, reintubation,
cuff pressure, frequency of suction, and mortality rate were measured
and recorded.
Ventilator-associated pneumonia preventive measures were applied
to all patients according to VAP bundle: (1) head elevation of 45°, (2)
protocolized enteral feeding, (3) sedation with washout periods, (4)
oral hygiene with chlorehixidine, (5) universal hand washing, and (6)
pantoprazol for stress ulcer prophylaxis. All patients received
154 A. Mahmoodpoor et al. / Journal of Critical Care 38 (2017) 152–156

ventilatory support as volume control mode for full support and pres- Table 2
sure support for partial support. Microbiologic pathogens isolated from the VAP patients during study

Diagnosis of VAP was suspected in patients receiving mechanical Group C Group E P

ventilation for more than 48 hours by clinically infection pulmonary (n = 46) (n = 30)
score (CPIS). The CPIS is a clinical score of 0 to 12 based on the following Methicillin-sensitive Staphylococcus aureus 1 (2.2%) 0 (0.0%) .315
6 variables: body temperature, leukocyte count, volume and character Methicillin-resistant S aureus 3 (6.5%) 1 (3.3%) .306
of tracheal secretions, arterial oxygenation, and chest radiograph find- Enterobacteriaceae 3 (6.5%) 1 (3.3%) .306
Pseudomonas aeruginosa 3 (6.5%) 2 (6.7%) .645
ings. It has a sensitivity of 72% to 80% and a specificity of 85% to 95% in
Acinetobacter spp 3 (6.5%) 0 (0.0%) .078
detection of VAP [24]. Bronchoalveolar lavage was performed for Total 13 (28.3%) 4 (13.2%) .015
every patients with CPIS values more than 6. Microbial analyses includ-
ed Gram staining, quantitative culture counts of colony-forming units,
and antibiotic sensitivity of tracheal aspirate specimens. Any growth 4. Discussion
of any bacterial pathogens in excess of 104 colony-forming units in
quantitative cultures was required to confirm the diagnosis of VAP in Results of this study showed that EVAC tubes decreased incidence of
patients who were mechanically ventilated for at least 48 hours. Evalu- VAP significantly compared with conventional tubes. Although the fre-
ation of the VAP incidence in each group was set as the primary quency of VAP was reduced, the mortality rate was unchanged suggest-
outcome measure of the study and presented as VAPs/1000 ventilator- ing that other confounding factors may have contributed to result in the
days. Secondary outcome measures were ICU length of stay, ventila- study. Although not statistically significant, the overall rate of mortality,
tor-free days, and hospital length of stay. The person who collected ICU length of stay, and hospital length of stay were less in EVAC group
the data was blinded to study. Mortality rate was also recorded for all compared with conventional tubes. The major route for acquiring VAP
patients during their hospital stay. is oropharyngeal colonization by the endogenous flora or by pathogens
acquired exogenously from the ICU environment [19-22]. Therefore,
2.3. Statistical analysis every intervention reducing the leakage of secretions or eradicating
these secretions would theoretically reduce VAP. Conventional ETTs
All obtained data were analyzed using SPSS 22.0 software (IBM, do not permit aspiration of subglottic secretions. Advent of Evac tubes
Chicago, Ill). Kolmogorov-Smirnov battery was performed to test the has permitted aspiration of subglottic secretions, thus preventing the
normality of distribution for continuous variables. Continuous variables aspiration of accumulated subglottic secretions. Cuff material is also im-
were reported as mean ± SD in case of normal distribution, or median portant in the development of VAP. When a conventional ETT is inflated
and interquartile range in case normality was rejected. Categorical in the trachea to achieve a clinical seal, the excess material folds over it-
variables were presented as frequency (%) and χ2 tests were used for self developing channels. These channels allow subglottic secretions to
their comparison. pass over the folds into the lower respiratory tract which in turn in-
creases the risk of VAP [1,15].
3. Results Fluid leakage pass the tracheal tube has remained an unresolved
problem with conventional ETTs; yet, there are some trials emphasizing
No statistically significant difference was found between the 2 that polyurethane cuffs are associated with lower fluid or air leakage,
groups regarding age, sex, APACHE II score, PaO2/FIO2, and VAP risk fac- and even VAP incidence than conventional ETTs with polyvinyl chloride
tors at baseline. Intensive care unit admission causes of patients are cuffs [5,14,25]. Our study revealed that Evac tubes significantly reduced
shown in Table 1. Multitrauma and sepsis were the most common the incidence of VAP compared with conventional tubes in critically ill
causes of admission to ICU in both studied groups. Mean CPIS for groups
C and E were 6 and 5, respectively. Microbiological findings of patients Table 3
in 2 groups are shown in Table 2. Gram-negative bacteria was found Studied variables and their comparison between the 2 groups
in 75% and 69% of positive cultures in group E and group C, respectively. Group C Group E P OR 95% CI
The mean cuff pressure in group E was significantly less than group C (n = 138) (n = 138)
(P b .001; Table 3). Frequency of intraluminal suction, mechanical-free Age (y) 54.5 ± 18.1 54.0 ± 19.2 .91 – –
days, reintubation, PaO2/FIO2, and mortality rate were statistically simi- (18-79) (18-78)
lar between the 2 groups (P N .05; Table 3). Incidence of VAP was signif- Cuff pressure (mm 27.0 ± 4.7 23.7 ± 2.3 b.001 – –
icantly less in group E compared with group C (P = .015; Table 3). The Hg) (16-33) (19-28)
No. of suctioning 8.8 ± 1.7 8.5 ± 1.6 .38 – –
mean cuff pressure was 24.2 ± 4.1 and 25.5 ± 4.0 cm H2O in patients (daily) (6-13) (6-13)
with and without VAP, respectively (P = .25). Intensive care unit and Duration of 12.3 ± 10.5 11.6 ± 7.1 .71 – –
hospital length of stay in group are shown in Table 3. No adverse effect ventilation (d) (4-61) (4-37)
was reported during the study regarding TaperGuard EVAC tubes. PaO2/FIO2 191 ± 28 173 ± 19 .12 – –
APACHE II 21.4 ± 4.4 22.6 ± 5.1 .25 – –
(16-37) (17-37)
Table 1 ISS 22.4 ± 3.5 24.1 ± 4.2 .18 – –
ICU admission causes of patients Sex
Male 102 84 .23 1.72 0.71-4.20
Underlying disease Group C (n = 138) Group E (n = 138)
Female 39 51
Multi trauma 39 (29.5%) 45 (34.9%) Reintubation 12 (8.7%) 9 (6.5%) .22 2.24 0.60-8.33
Sepsis/severe sepsis 25 (18.2%) 22 (16.3%) VAPα 46 (33.3%) 30 (21.7%) .015 6.13 1.62-23.14
Embolic syndromes 17 (13.4%) 11 (4.5%) Early onset 17 (12.3%) 14 (10.1%) .15
Traumatic brain injury 25 (18.2%) 27 (20.9%) Late onset 29 (21.0%) 16 (11.6%) .021
Myocardial infarction 3 (2.2%) 4 (2.9%) ICU LOS 18 ± 10 15 ± 5 (6-44) .33 – –
Acute state of confusion 6 (4.5%) 1 (0.1%) (7-68)
Hypoxemic encephalopathy 6 (4.5%) 7 (4.5%) Hospital LOS 29.5 ± 9.9 27.2 ± 7.0 .51 – –
Adult respiratory distress syndrome 3 (2.2%) 1 (0.1%) (19-72) (20-69)
Malignancy 7 (4.5%) 10 (9.3%) Ventilator-free days 6±1 4±2 .22 – –
Major operation 7 (4.5%) 6 (4.5%) Mortality 48 (37.2%) 36 (27.3%) .33 .64 0.26-1.57
Intoxication 0 (0.0%) 4 (2.9%)
α indicates VAP rate per 1000 ventilator-days; LOS, length of stay; ISS, Injury Severity
P values for all of the variables are nonsignificant between the 2 groups. Score.
 A. Mahmoodpoor et al. / Journal of Critical Care 38 (2017) 152–156
patients subjected to prolonged mechanical ventilation. Despite being
within normal ranges, mean cuff pressure was lower in group E com-
pared with group C; interestingly, VAP incidence was lower in group
E. This might have been due to the superior effects of cuff design and
subglottic secretion drainage. The efficacy of subglottic secretion drain-
age in reducing the occurrence of VAP has already been suggested in a
number of studies [5,7,26]. Likewise, 2 recent meta-analyses have con-
firmed the protective effects of subglottic secretion aspiration in the in-
cidence of VAP [27,28].
However, some studies only showed that subglottic secretion drain-
age could reduce only colonization [29]. Cook et al [30] used an evi-
dence-based approach to show the overall usefulness of CASS. They
concluded that individual clinicians need to decide whether the admin-
istration of CASS will significantly contribute to their VAP prevention
strategy. This will, in large part, be based on the preexisting strategies
that the hospital has for VAP prevention, the additional costs associated
with the use of CASS, and the clinical benefits realized with the applica-
tion of CASS. Conflicting results about the effect of tubes equipped with
subglottic secretion drainage on the incidence of VAP might be because
of different compliance of VAP prevention bundle in different studies. It
seems that the effects of these tubes are less in situations of high com-
pliance with VAP prevention bundles.
In contrast, some studies have suggested that subglottic secretion
drainage insignificantly decrease the incidence of VAP [4,8,31]. The
study of Rello et al [32] was the first to report failure of subglottic secre-
tion aspiration in VAP prevention. They showed that the failure was due
to blockage of the subglottic suction port by suctioned tracheal mucosa
[33]. Animal studies carried out in this field have revealed that aspira-
tion of subglottic secretion could cause severe tracheal injury in an
area immediately adjacent to the subglottic suction port [33].
Discontinuing of subglottic aspiration seems to be an appropriate ap-
proach to decrease this injury. Recent guidelines recommend the use
of subglottic secretion drainage to reduce early- and late-onset VAP [3,
34]; however, there is no difference in VAP reduction when comparing
continuous (relative risk, 0.50; 95% confidence interval [CI], 0.37-0.66)
and intermittent (relative risk, 0.59; 95% CI, 0.47-0.74) suction [28]. A
risk-benefit analysis should be considered when making the decision
about using either technique of subglottic secretion drainage. Although
a direct comparison of intermittent and continuous subglottic secretion
drainage has not been done, lower risk of injury is theoretically possible
with intermittent subglottic secretion drainage. We therefore suctioned
subglottic secretions every 6 hours instead of the continuous approach
in the present study. Results of another study showed that the combina-
tion of subglottic secretion drainage and continuous control of endotra-
cheal cuff pressure reduced the incidence of pneumonia and health
costs [35]. Although VAP incidence was different between the 2 groups
in this study, mortality rate was not of significant difference between
the 2 groups which might be due to small sample size, heterogeneity
of patients in ICU, and short duration of follow-up. However, despite
these benefits, these tubes are not used routinely [36], and this is likely
because of conflicting clinical trial evidence, safety concerns surround-
ing laryngeal/tracheal damage caused by the stiffer nature of these
tubes, suction damage to the tracheal mucosa, the fact that the studies
often only show that early VAP is reduced, and the higher cost of the
tubes. Of 9 prospective, randomized controlled studies of subglottic se-
cretion drainage, 6 did not consider the adverse effects of subglottic se-
cretion drainage, 2 reported no adverse events, and 1 reported a
significant increase in the risk of laryngeal edema requiring reintubation
in patients intubated with an subglottic secretion drainage tube [37]. A
recent meta-analysis confirmed that subglottic secretion drainage was
beneficial in preventing VAP, but we need more studies to show its ef-
fect on late-onset VAP and also comparison of continuous vs intermit-
tent subglottic secretion drainage [38]. Bowton et al [39] in their study
showed that the use of a tapered-cuff ETT was not associated with a re-
duction in the VAP rate where there was a high adherence to the VAP
prevention bundle. This was in contrast to our findings, which could
155
be because of different population used in these 2 studies. Damas et al
[40] in a study showed that subglottic secretion suctioning resulted in
a significant reduction of VAP prevalence associated with a significant
decrease in antibiotic use, but ventilator-associated condition occur-
rence did not differ between groups and appeared more related to
other medical features than VAP. Other reasons for relatively low inci-
dences of VAP in our study were a high compliance rate for VAP bundle
(80%) in our health care workers, a strict exclusion criteria, and low to
moderate injury scores of patients. Regarding late- vs early-onset VAP,
our results showed that using TaperGuard tubes significantly lower
the incidence of late-onset VAP in patients, which was similar to results
of previous studies [15]. This is an important finding as late-onset VAP
has high mortality rate because of its causative organism.
Our study was limited because it was a single-center study per-
formed in a surgical ICU; our results could not necessarily be extrapolat-
ed to medical ICU patients. In this study, cuff pressure was measured
intermittently not continuously so sometimes during the study, cuff
pressures were not in normal range. We also did not assay antibiotic
consumption. As mentioned previously, we did not factor in the cost
and adverse effects of these tubes in this study. That all of the practi-
tioners were not blinded is another weakness of this study. However,
a recent study suggested that the use of clinical criteria to establish
the diagnosis of VAP was acceptable because of its greater diagnostic
sensitivity, compared with bronchoscopically obtained cultures, and
its good correlation with hospital mortality. Good results of our study
in VAP prevention might have been due to the use of tubes, which
were equipped with subglottic secretion drainage, a well-designed
cuff shape (cone shape), and thin cuff material (polyurethane) plus
using intermittent cuff pressure monitoring.
We conclude that the use of TaperGuard Evac tubes with intermit-
tent subglottic secretion drainage is associated with a significant de-
crease in VAP incidence in critically ill patients. Efficacy of subglottic
secretion drainage is influenced by intermittent vs continuous aspira-
tion, viscosity of secretions, patient position, presence or absence of
swallowing, and position of Evac tube in the airway. Every physician
should consider that decreasing the incidence of VAP requires the im-
plementation of multiple interventions at the same time in bundles, as
single intervention has not been shown to be successful. Therefore, larg-
er multicenter trials focusing on these variables are recommended in
the prevention of VAP.
Authors' contribution
HH: statistical analysis, manuscript editing; MH: concept of research,
data collection, manuscript drafting; KSh: literature review, data collec-
tion, manuscript editing; SEJG: data collection, statistical analysis, man-
uscript editing; SS: literature review, manuscript drafting; AM: concept
of manuscript, data collection, manuscript drafting, manuscript editing;
ZHKh: concept of idea, data collection, manuscript drafting; NDN: criti-
cal review, manuscript drafting. All authors read and approved the final
version of manuscript.
Competing interest: The authors did not have any competing
interest.
Acknowledgment
We acknowledge the ICU staff of Shohada Hospital, especially Mr
Shahrokh Teshnehdel and Mr Qorbanali Tarinezhad for their coopera-
tion and Research Chancellor of Tabriz University of Medical Sciences
for their support. Covidien company did not have any role in this study.
References
[1] Pneumatikos IA, Dragoumanis CK, Bouros DE. Ventilator-associated pneumonia or
endotracheal tube-associated pneumonia? An approach to the pathogenesis and
preventive strategies emphasizing the importance of endotracheal tube. Anesthesi-
ology 2009;110:673–80.
156 A. Mahmoodpoor et al. / Journal of Critical Care 38 (2017) 152–156
[2] Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, et al. Epidemiology
and outcomes of ventilator-associated pneumonia in a large US database. Chest
2002;122:2115–21.
[3] American Thoracic S, Infectious Diseases Society of A. Guidelines for the manage-
ment of adults with hospital-acquired, ventilator-associated, and healthcare-
associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.
[4] Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration
of subglottic secretions in cardiac surgery patients. Chest 1999;116:1339–46.
[5] Mahul P, Auboyer C, Jospe R, Ros A, Guerin C, el Khouri Z, et al. Prevention of noso-
comial pneumonia in intubated patients: respective role of mechanical subglottic se-
cretions drainage and stress ulcer prophylaxis. Intensive Care Med 1992;18:20–5.
[6] Smulders K, van der Hoeven H, Weers-Pothoff I, Vandenbroucke-Grauls C. A ran-
domized clinical trial of intermittent subglottic secretion drainage in patients receiv-
ing mechanical ventilation. Chest 2002;121:858–62.
[7] Valles J, Artigas A, Rello J, Bonsoms N, Fontanals D, Blanch L, et al. Continuous aspi-
ration of subglottic secretions in preventing ventilator-associated pneumonia. Ann
Intern Med 1995;122:179–86.
[8] Bouza E, Perez MJ, Munoz P, Rincon C, Barrio JM, Hortal J. Continuous aspiration of
subglottic secretions in the prevention of ventilator-associated pneumonia in the
postoperative period of major heart surgery. Chest 2008;134:938–46.
[9] Dragoumanis CK, Vretzakis GI, Papaioannou VE, Didilis VN, Vogiatzaki TD,
Pneumatikos IA. Investigating the failure to aspirate subglottic secretions with the
Evac endotracheal tube. Anesth Analg 2007;105:1083–5 [table of contents].
[10] Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated pneumonia: an
evidence-based systematic review. Ann Intern Med 2003;138:494–501.
[11] Iregui M, Kollef MH. Prevention of ventilator-associated pneumonia: selecting inter-
ventions that make a difference. Chest 2002;121:679–81.
[12] Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated
pneumonia. Crit Care Med 2004;32:1396–405.
[13] Dullenkopf A, Gerber A, Weiss M. Fluid leakage past tracheal tube cuffs: evaluation
of the new Microcuff endotracheal tube. Intensive Care Med 2003;29:1849–53.
[14] Dullenkopf A, Schmitz A, Frei M, Gerber AC, Weiss M. Air leakage around endotra-
cheal tube cuffs. Eur J Anaesthesiol 2004;21:448–53.
[15] Lorente L, Lecuona M, Jimenez A, Mora ML, Sierra A. Influence of an endotracheal
tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am
J Respir Crit Care Med 2007;176:1079–83.
[16] Tsuboi S, Miyashita T, Yamaguchi Y, Yamamoto Y, Sakamaki K, Goto T. The
TaperGuard endotracheal tube intracuff pressure increase is less than that of the
Hi-Lo tube during nitrous oxide exposure: a model trachea study. Anesth Analg
2013;116:609–12.
[17] Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med
2002;165:867–903.
[18] Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secre-
tion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J
Med 2005;118:11–8.
[19] Niederman MS. Can optimal management prevent mortality in ventilator-associated
pneumonia? Crit Care Med 2002;30:1916–7.
[20] Ramirez P, Ferrer M, Torres A. Prevention measures for ventilator-associated pneu-
monia: a new focus on the endotracheal tube. Curr Opin Infect Dis 2007;20:190–7.
[21] Ranes JL, Gordon SM, Chen P, Fatica C, Hammel J, Gonzales JP, et al. Predictors of
long-term mortality in patients with ventilator-associated pneumonia. Am J Med
2006;119:897.e813–99.
[22] Valles J, Pobo A, Garcia-Esquirol O, Mariscal D, Real J, Fernandez R. Excess ICU mor-
tality attributable to ventilator-associated pneumonia: the role of early vs late onset.
Intensive Care Med 2007;33:1363–8.
[23] Mujica-Lopez KI, Pearce MA, Narron KA, Perez J, Rubin BK. In vitro evaluation of en-
dotracheal tubes with intrinsic suction. Chest 2010;138:863–9.
[24] Zilberberg MD, Shorr AF. Ventilator-associated pneumonia: the clinical pulmonary
infection score as a surrogate for diagnostics and outcome. Clin Infect Dis 2010;
51(Suppl. 1):S131–5.
[25] Mahmoodpoor A, Peyrovi-far A, Hamishehkar H, Bakhtyiari Z, Mirinezhad MM,
Hamidi M, et al. Comparison of prophylactic effects of polyurethane cylindrical or ta-
pered cuff and polyvinyl chloride cuff endotracheal tubes on ventilator-associated
pneumonia. Acta Med Iran 2013;51:461–6.
[26] Yang CS, Qiu HB, Zhu YP, Huang YZ, Xu XT, Gao L. Effect of continuous aspiration of
subglottic secretions on the prevention of ventilator-associated pneumonia in me-
chanically ventilated patients: a prospective, randomized, controlled clinical trial.
Zhonghua Nei Ke Za Zhi 2008;47:625–9.
[27] Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland DK. Subglottic secre-
tion drainage for the prevention of ventilator-associated pneumonia: a systematic
review and meta-analysis. Crit Care Med 2011;39:1985–91.
[28] Scherzer R. Subglottic secretion aspiration in the prevention of ventilator-associated
pneumonia: a review of the literature. Dimens Crit Care Nurs 2010;29:276–80.
[29] Lacherade JC, De Jonghe B, Guezennec P, Debbat K, Hayon J, Monsel A, et al. Intermit-
tent subglottic secretion drainage and ventilator-associated pneumonia: a multicen-
ter trial. Am J Respir Crit Care Med 2010;182:910–7.
[30] Cook DJ, Hebert PC, Heyland DK, Guyatt GH, Brun-Buisson C, Marshall JC, et al. How
to use an article on therapy or prevention: pneumonia prevention using subglottic
secretion drainage. Crit Care Med 1997;25:1502–13.
[31] Stohr G, Kunze M, Ohmann C, Roher HD, Becker H. Cause-oriented prevention of
nosocomial pneumonia: the HI-LO EVAC tube. Langenbecks Arch Chir Suppl
Kongressbd 1998;115:1071–3.
[32] Rello J, Sonora R, Jubert P, Artigas A, Rue M, Valles J. Pneumonia in intubated pa-
tients: role of respiratory airway care. Am J Respir Crit Care Med 1996;154:111–5.
[33] Berra L, De Marchi L, Panigada M, Yu ZX, Baccarelli A, Kolobow T. Evaluation of con-
tinuous aspiration of subglottic secretion in an in vivo study. Crit Care Med 2004;32:
2071–8.
[34] Lorente L, Lecuona M, Jimenez A, Cabrera J, Mora ML. Subglottic secretion drainage
and continuous control of cuff pressure used together save health care costs. Am J
Infect Control 2014;42:1101–5.
[35] Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, Cdc, et al. Guidelines for
preventing health-care–associated pneumonia, 2003: recommendations of CDC
and the Healthcare Infection Control Practices Advisory Committee. MMWR
Recomm Rep 2004;53:1–36.
[36] Gentile MA, Siobal MS. Are specialized endotracheal tubes and heat-and-moisture
exchangers cost-effective in preventing ventilator associated pneumonia? Respir
Care 2010;55:184–96 [discussion 196–187].
[37] Girou E, Buu-Hoi A, Stephan F, Novara A, Gutmann L, Safar M, et al. Airway colonisa-
tion in long-term mechanically ventilated patients. Effect of semi-recumbent posi-
tion and continuous subglottic suctioning. Intensive Care Med 2004;30:225–33.
[38] Wang F, Bo L, Tang L, Lou J, Wu Y, Chen F, et al. Subglottic secretion drainage for
preventing ventilator-associated pneumonia: an updated meta-analysis of random-
ized controlled trials. J Trauma Acute Care Surg 2012;72:1276–85.
[39] Bowton DL, Hite RD, Martin RS, Sherertz R. The impact of hospital-wide use of a ta-
pered-cuff endotracheal tube on the incidence of ventilator-associated pneumonia.
Respir Care 2013;58:1582–7.
[40] Damas P, Frippiat F, Ancion A, Canivet JL, Lambermont B, Layios N, et al. Prevention
of ventilator-associated pneumonia and ventilator-associated conditions: a random-
ized controlled trial with subglottic secretion suctioning. Crit Care Med 2015;43:
22–30.