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  • Nicolas Marjanovic
    Affiliations
    Service des Urgences et SAMU 86 Centre 15, CHU de Poitiers, Poitiers, France

    Université de Poitiers, Faculté de Médecine-Pharmacie, Poitiers, France

    INSERM CIC1402 Team 5 Acute Lung Injury and Ventilatory support, Poitiers, France
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  • Jérémy Guenezan
    Affiliations
    Service des Urgences et SAMU 86 Centre 15, CHU de Poitiers, Poitiers, France

    INSERM U1070, Pharmacologie des Agents anti-infectieux, Poitiers, France
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  • Olivier Mimoz
    Correspondence
    CORRESPONDENCE TO: Olivier Mimoz, PhD
    Affiliations
    Service des Urgences et SAMU 86 Centre 15, CHU de Poitiers, Poitiers, France

    Université de Poitiers, Faculté de Médecine-Pharmacie, Poitiers, France

    INSERM U1070, Pharmacologie des Agents anti-infectieux, Poitiers, France
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  • for theAGATE Study Group
    Author Footnotes
    ∗ Collaborators from the AGATE Study Group are listed in the Acknowledgments.
  • Author Footnotes
    ∗ Collaborators from the AGATE Study Group are listed in the Acknowledgments.
      To the Editor:
      We thank Lakhal et al for their great interest in our study.
      • Marjanovic N.
      • Boisson M.
      • Asehnoune K.
      • et al.
      Continuous pneumatic regulation of tracheal cuff pressure to decrease ventilator-associated pneumonia in mechanically ventilated trauma patients: the AGATE multicenter randomized controlled study.
      The authors suggest frequent disconnection of the pneumatic device from the tracheal cuff to explain failure of the intervention. Overall, 778 device interruptions were recorded during the study (three per patient on average), which corresponds to only 1.4% of mechanical ventilation time, mainly (65%) for patient transfer to the radiology department or the operating room. These short periods of disconnection could have led to episodes of under-inflation of the tracheal cuff and thus aspiration of the oropharyngeal content; however, we do not believe that they alone can explain the lack of benefit of the intervention.
      Transporting mechanically ventilated patients carries a high risk of aspiration,
      • Fanara B.
      • Manzon C.
      • Barbot O.
      • Desmettre T.
      • Capellier G.
      Recommendations for the intra-hospital transport of critically ill patients.
      and device disconnections occasionally may cause its misuse through air leakage related to errors in the position of the three-way stopcock and/or default in device recalibration. Nevertheless, none of these situations were reported by nurses caring for the patients. We agree with Lakhal et al that the use of smaller, transportable continuous tracheal cuff pressure control devices, which were not available at the time we began our study, should be preferred to avoid device disconnections during patient transport or care, although no studies confirming their efficacy have yet been published.
      • Dauvergne J.E.
      • Geffray A.L.
      • Asehnoune K.
      • Rozec B.
      • Lakhal K.
      Automatic regulation of the endotracheal tube cuff pressure with a portable elastomeric device: a randomised controlled study.
      • Marjanovic N.
      • Laupland K.B.
      • Mimoz O.
      Feasibility but unclear benefit of minimising endotracheal cuff under inflation using an elastomeric device.
      Finally, if our results are confirmed by others, the authors encourage the exploration of pathways other than inhalation of oropharyngeal contents as a starting point for the development of ventilator-associated pneumonia (VAP). Another hypothesis, also discussed in the article, is the timing of onset of aspiration. Severe trauma patients are often admitted to the ICU several hours after tracheal intubation, which is the time to transfer them from the scene to the hospital, to carry out initial assessment and eventually to be treated in the operating room. Aspiration of oropharyngeal secretions before placement of the continuous cuff pressure control device cannot be excluded.
      Health care-associated infections remain a major burden of patients in critical care, with VAPs being the most common and among the ones most frequently associated with poor outcome. Moreover, VAPs accounts for more than one-half of the antibiotic treatments prescribed in the ICU and favor the appearance of bacterial resistance. Fighting them is crucial, with the use of a multifactorial approach combining all the components likely to prevent them.
      • Papazian L.
      • Klompas M.
      • Luyt C.E.
      Ventilator-associated pneumonia in adults: a narrative review.
      Continuous tracheal cuff pressure monitoring has theoretic advantages but, in the absence of clinical validation based on robust endpoints, cannot be recommended routinely.

      Acknowledgments

      AGATE Study Group collaborators: Karim Asehnoune, PhD, Service d’Anesthésie-Réanimation chirurgicale, CHU de Nantes, France; Guillaume Besch, PhD, Department of Anesthesiology and Intensive Care Medicine, CHU de Besancon, Besançon, France; Matthieu Boisson, PhD, INSERM U1070, Pharmacologie des Agents anti-infectieux, Université de Poitiers, France, Service d’Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France; Bélaid Bouhemad, PhD, Department of Anesthesiology and Intensive Care, CHU Dijon, France; Elodie Caumon, MSc, Department of Perioperative Medicine, Neurocritical Care Unit, Neuro-Anesthesiology Clinic, CHU de Clermont-Ferrand, France; Russel Chabanne, MD, Department of Perioperative Medicine, Neurocritical Care Unit, Neuro-Anesthesiology Clinic, CHU de Clermont-Ferrand, France; Thien-Nga Chamaraux-Tran, PhD, Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service d’Anesthésie-Réanimation & Médecine Péri-Opératoire, Strasbourg, France; Raphael Cinotti, MD, Service d’Anesthésie-Réanimation chirurgicale, CHU de Nantes, France; Claire Dahyot-Fizelier, PhD, INSERM U1070, Pharmacologie des Agents anti-infectieux, Université de Poitiers, France. Service d’Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France; Claire-Marie Drevet, MD, Department of Anesthesiology and Intensive Care, CHU Dijon, France; Dominique Falcon, MD, Pole Anesthésie Réanimation, CHU de Grenoble, France; Arnaud Foucrier, MD, Anesthésie-Réanimation, AP-HP Nord Hôpital Beaujon, Paris, France; Denis Frasca, PhD, INSERM U1246, Methods in Patients-centered outcomes and Health Research – SPHERE, Nantes, France. Service d’Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France; Soizic Gergaud, MD, Département d’Anesthésie-Réanimation, CHU d’Angers, France; Marc Ginet, MD, Department of Anesthesiology and Intensive Care Medicine, CHU de Besancon, Besançon, France; Philippe Gouin, MD, Surgical Intensive Care Unit, Rouen University Hospital, France; Florian Grimaldi, PhD, Pole Anesthésie Réanimation, CHU de Grenoble, France; Pierre-Gildas Guitard, MD, Surgical Intensive Care Unit, Rouen University Hospital, France; Emmanuelle Hammad, MD, Aix-Marseille Université, Service d’Anesthésie et de Réanimation, Assistance Publique Hôpitaux Universitaires de Marseille, Hôpital Nord, Marseille, France; Carole Ichai, PhD, Service de Réanimation Polyvalente, CHU de Nice, France; Lilit Kelesyan, MD, Anesthésie-Réanimation, AP-HP Nord Hôpital Beaujon, Paris, France; Joe de Keizer, MSc, Plateforme Méthodologie-Biostatistique-Data-Management, CHU de Poitiers, France; Thomas Kerforne, PhD, Service d’Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France; Sigismond Lasocki, PhD, Département d’Anesthésie-Réanimation, CHU d’Angers, France; Marc Leone, PhD, Aix Marseille Université, Service d’Anesthésie et de Réanimation, Assistance Publique Hôpitaux Universitaires de Marseille, Hôpital Nord, Marseille, France; Sébastien Leduc, MD, Service de Réanimation Polyvalente, CHU de Nice, France; Jean-Yves Lefrant, PhD, EA 2992 IMAGINE, Université de Montpellier, Montpellier, France, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes, France; Maxime Leger, MD, Département d’Anesthésie-Réanimation, CHU d’Angers, France; Pierre-Olivier Ludes, MD, Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service d’Anesthésie-Réanimation & Médecine Péri-Opératoire, Strasbourg, France; Laurent Muller, PhD, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes, France; Abdelouaid Nadji, MD, Department of Anesthesiology and Intensive Care, CHU Dijon, France; Catherine Paugam-Burtz, PhD, Anesthésie-Réanimation, AP-HP Nord Hôpital Beaujon, Paris, France; Sébastien Pili-Floury, PhD, Department of Anesthesiology and Intensive Care Medicine, CHU de Besancon, Besançon, France, EA3920 and SFR-FED 4234 INSERM, Université de Franche-Comté, Besançon, France; Marie-Hélène Po, MD, Aix-Marseille Université, Service d’Anesthésie et de Réanimation, Assistance Publique Hôpitaux Universitaires de Marseille, Hôpital Nord, Marseille, France; Julien Pottecher, PhD, Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service d’Anesthésie-Réanimation & Médecine Péri-Opératoire, Strasbourg, France, Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg, ER3072, Strasbourg, France; Hervé Quintard, PhD, Service de Réanimation Polyvalente, CHU de Nice, France; Claire Roger, PhD, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes, France; Antoine Roquilly, PhD, Service d’Anesthésie-Réanimation chirurgicale, CHU de Nantes, France; Sabrina Seguin, MSc, Service d’Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France; Marc Veber, PhD, Surgical Intensive Care Unit, Rouen University Hospital, France.

      References

        • Marjanovic N.
        • Boisson M.
        • Asehnoune K.
        • et al.
        Continuous pneumatic regulation of tracheal cuff pressure to decrease ventilator-associated pneumonia in mechanically ventilated trauma patients: the AGATE multicenter randomized controlled study.
        Chest. 2021; 160: 499-508
        • Fanara B.
        • Manzon C.
        • Barbot O.
        • Desmettre T.
        • Capellier G.
        Recommendations for the intra-hospital transport of critically ill patients.
        Crit Care. 2010; 14: R87
        • Dauvergne J.E.
        • Geffray A.L.
        • Asehnoune K.
        • Rozec B.
        • Lakhal K.
        Automatic regulation of the endotracheal tube cuff pressure with a portable elastomeric device: a randomised controlled study.
        Anaesth Crit Care Pain Med. 2020; 39: 435-441
        • Marjanovic N.
        • Laupland K.B.
        • Mimoz O.
        Feasibility but unclear benefit of minimising endotracheal cuff under inflation using an elastomeric device.
        Anaesth Crit Care Pain Med. 2020; 39: 419-420
        • Papazian L.
        • Klompas M.
        • Luyt C.E.
        Ventilator-associated pneumonia in adults: a narrative review.
        Intensive Care Med. 2020; 46: 888-906

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