ARTICLE IN PRESS

Journal of Cardiothoracic and Vascular Anesthesia 000 (2020) 18

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Journal of Cardiothoracic and Vascular Anesthesia

journal homepage: www.jcvaonline.com

Original Article
Effect of Perioperative Subglottic Secretion Drainage
on Ventilator-Associated Pneumonia After Cardiac
Surgery: A Retrospective, Before-and-After Study
Karam Nam, MD*, Jung-Bin Park, MD*,
Wan Beom Park, MD, PhDy, Nam Joong Kim, MD, PhDy,
Younghae Cho, BSz, Hwan Suk Jang, MD*,
Ho Young Hwang, MD, PhDx, Sue Hyun Kim, MDx,
Yeiwon Lee, MDx, Seohee Lee, MD*, Jinyoung Bae, MD*,
{
Youn Joung Cho, MD, PhD*, Eun Jin Kim, RN, MSN, CIC ,
k *, 1
Minjeong Kim, RN, BSN , Yunseok Jeon, MD, PhD
*
Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National Uni-
versity College of Medicine, Seoul, Korea
y
Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of
Medicine, Seoul, Korea
z
Department of Statistics, Sungkyunkwan University, Seoul, Korea
x
Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National
University College of Medicine, Seoul, Korea
{
Department of Infection Prevention and Control, Seoul Metropolitan Government-Seoul National University
Boramae Medical Center, Seoul, Korea
k
Infection Control Centre, Seoul National University Hospital, Seoul, Korea

Objectives: Although postoperative subglottic secretion drainage prevents ventilator-associated pneumonia (VAP) after cardiac surgery, its role
during the perioperative period is unclear. For the present study, the effect of subglottic secretion drainage during and after cardiac surgery on
postoperative VAP was investigated.
Design: Retrospective, single-center, before-and-after study.
Setting: Perioperative care of cardiac surgical patients in a tertiary university hospital.
Participants: Adult patients who underwent cardiac surgery from January 2013December 2018.
Interventions: Conventional and subglottic suctioning endotracheal tubes were used in the control and intervention groups before and after a
change in institutional policy, respectively. In the intervention group, subglottic secretion drainage was performed continuously during surgery
and intermittently after surgery.
Measurements and Main Results: The risk of postoperative VAP, identified by the National Healthcare Safety Network surveillance definition
algorithm, was compared by weighted logistic regression. Logistic regression analyses, with propensity score matching and inverse probability
weighting, also were performed. A total of 2,576 patients were analyzed (control [n = 2108]; intervention [n = 468]). Postoperative VAP occurred
less frequently in the intervention group (1/468 [0.2%]) compared with the control group (30/2,108 [1.4%]). In the multivariate weighted logistic
regression analysis, the risk of VAP after cardiac surgery was significantly lower in the intervention group than in the control group (odds ratio
0.29; 95% confidence interval 0.14-0.58). Similar results were obtained in multivariate analyses after propensity score matching (odds ratio
0.04; 95% confidence interval 0.01-0.14) and inverse probability weighting (odds ratio 0.16; 95% confidence interval 0.05-0.42).

1
Address reprint requests to Yunseok Jeon, MD, PhD, Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National
University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea.
E-mail address: jeonyunseok@gmail.com (Y. Jeon).

https://doi.org/10.1053/j.jvca.2020.09.126
1053-0770/Ó 2020 Published by Elsevier Inc.
 ARTICLE IN PRESS
2 K. Nam et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2020) 18

Conclusions: Routine perioperative subglottic secretion drainage using subglottic suctioning endotracheal tubes in patients undergoing cardiac
surgery was associated with a reduction in the risk of VAP after surgery.
Ó 2020 Published by Elsevier Inc.

Key Words: cardiac surgery; subglottic suctioning; ventilator-associated pneumonia

VENTILATOR-associated pneumonia (VAP) after cardiac
surgery is common, with an incidence of more than 6%.1 Aspi-
ration of infected secretions in the subglottic space plays a piv-
otal role in the pathogenesis of VAP.2,3 Subglottic secretion
drainage (SSD) long has been studied to prevent the develop-
ment of VAP.4 The vast majority of prior studies were per-
formed in critically ill patients requiring prolonged
mechanical ventilation, and the Centers for Disease Control
and Prevention (CDC) recommended SSD as a preventive
measure for VAP in these patients.5 However, previous studies
on perioperative SSD in patients undergoing high-risk surgery,
such as cardiac surgery, are scarce.6 Furthermore, the results
of these prior studies were conflicting, and none evaluated the
effect of intraoperative SSD initiated upon intubation at the
beginning of surgery.7-9
Therefore, for the present study, the effect of SSD during
and after cardiac surgery on postoperative VAP was evaluated.
The routine use of subglottic suctioning endotracheal tubes
was implemented recently in the authors’ center. The authors
hypothesized that intraoperative SSD, accompanied by postop-
erative SSD, would significantly reduce the risk of VAP after
cardiac surgery. To evaluate this hypothesis, a single-center,
retrospective, before-and-after cohort study was conducted.
suctioning endotracheal tube (intervention group). Before this
change in policy, a conventional endotracheal tube (Shiley
cuffed basic endotracheal tube; Medtronic) was used without
SSD (control group).
Perioperative Management and Intervention
All patients during the study period underwent protocolized
perioperative management in the operating room and ICU,
with the exception of use of a subglottic suctioning endotra-
cheal tube as described later. Anesthesia was induced with
intravenous midazolam (0.10.2 mg/kg). When patients were
expected to be hemodynamically unstable, etomidate (0.15-
0.25 mg/kg) or ketamine (1-2 mg/kg) was used as an alterna-
tive. Rocuronium (0.6-1.2 mg/kg), vecuronium (0.1-0.2 mg/
kg), or cisatracurium (0.1-0.2 mg/kg) was administered for
neuromuscular blockade, and sufentanil (1-2 mg/kg) was
administered as an adjunctive anesthetic. After the induction
of anesthesia and tracheal intubation, mechanical ventilation
was started using a breathing circuit with a heat-and-moisture
exchanger (Mega Acer Kit; Ace Medical, Goyang, Korea).
Anesthesia was maintained using a target-controlled infusion

Methods
Study Design and Population

This was a single-center, before-and-after, retrospective

cohort study. The study protocol was approved by the Institu-
tional Review Board of the authors’ hospital on March 14,
2019 (H-1903-080-1017); the requirement for written
informed consent was waived because of the retrospective
nature of the study.
The analysis retrospectively included all adult patients
(19 y old) who underwent cardiac surgery (excluding heart
transplantation) at the authors’ tertiary teaching hospital from
January 2013December 2018. Patients intubated before sur-
gery, intubated using a double-lumen tube, who had pneumo-
nia before surgery, or who had undergone lung resection or
organ transplantation were excluded from the analysis. If a
patient underwent multiple cardiac surgeries during the study
period, only the first case was included. The routine use of an
endotracheal tube that permits SSD (Shiley evac oral endotra-
cheal tube with TaperGuard and Murphy eye; Medtronic Inc,
Minneapolis, MN) (Fig 1) was implemented on December 21,
2017, in both the operating room and the intensive care unit
(ICU). Thereafter, patients presenting for cardiac surgery were Fig 1. (A) Subglottic suctioning endotracheal tube and (B) its embedded suc-
intubated upon the induction of anesthesia using a subglottic tion conduit and opening.
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K. Nam et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2020) 18 3

of propofol and remifentanil. Vecuronium or cisatracurium Table 1

was infused continuously at 0.5-to-1.5 mg/kg/min during sur- Patient Characteristics
gery. Intraoperative transesophageal echocardiography was Control Intervention p Value
performed routinely in all patients. For preoperative antibiotic (n = 2108) (n = 468)
prophylaxis, vancomycin (1 g) or cefuroxime (750 mg) was
Demographics
administered to patients undergoing on-pump or off-pump sur- Age (y) 63.0 (12.9) 65.7 (12.2) < 0.001
gery, respectively, before skin incision. The same dose of van- Female 851 (40.4%) 172 (36.8%) 0.163
comycin or cefuroxime was repeated every 12 or eight hours, Body mass index (kg/m2) 23.9 (3.3) 24.4 (3.5) 0.001
respectively, until the first postoperative day. Smoker 382 (18.1%) 116 (24.8%) 0.001
Comorbidities
In the intervention group, SSD was applied continuously via Peptic ulcer disease 48 (2.3%) 10 (2.1%) 0.990
wall suction with a negative pressure of up to 20 mmHg during Hypertension 1052 (49.9%) 212 (45.3%) 0.080
surgery, per the manufacturer’s instructions. In addition, sub- Diabetes 563 (26.7%) 116 (24.8%) 0.426
glottic suctioning was performed for 10-to-15 seconds, with a Cerebrovascular disease 329 (15.6%) 122 (26.1%) < 0.001
COPD 42 (2.3%) 16 (3.4%) 0.087
negative pressure not exceeding 100-to-150 mmHg immedi- Asthma 48 (2.3%) 10 (2.1%) 0.990
ately after tracheal intubation and before withdrawal of a trans- Angina pectoris 760 (36.1%) 130 (27.8%) 0.001
esophageal echocardiographic probe when necessary. After the Atrial fibrillation 330 (15.7%) 91 (19.4%) 0.053
Myocardial infarction 131 (6.2%) 42 (9.0%) 0.040
completion of surgery, all patients were transferred to the ICU
Pulmonary oedema 72 (3.4%) 16 (3.4%) > 0.999
without extubation, and mechanical ventilation was continued. Chronic heart failure 176 (8.3%) 26 (5.6%) 0.053
In the ICU, intermittent SSD was performed on patients in the Chronic liver disease 121 (5.7%) 19 (4.1%) 0.181
intervention group by the attending nurses. Chronic kidney disease 560 (26.6%) 44 (9.4%) < 0.001
Medication history
Patients who were hemodynamically stable were placed in Aspirin 702 (33.3%) 158 (33.8%) 0.892
the head-up position (30-45 degrees) in the ICU. For postoper- Clopidogrel 354 (16.8%) 111 (23.7%) 0.001
ative sedation and analgesia, dexmedetomidine and remifenta- ACEi/ARB 800 (38.0%) 188 (40.2%) 0.400
nil were administered intravenously during mechanical Beta blocker 435 (20.6%) 151 (32.3%) < 0.001
Calcium channel blocker 740 (35.1%) 134 (28.6%) 0.009
ventilation. A heated humidifier (MR850; Fisher & Paykel Diuretics 732 (34.7%) 140 (29.9%) 0.053
Healthcare Limited, Auckland, New Zealand) was applied for Statin 720 (38.9%) 233 (49.8%) < 0.001
all patients undergoing mechanical ventilation. The endotra- Steroid 59 (2.8%) 7 (1.5%) 0.146
cheal cuff pressure was measured three times daily and main- Preoperative laboratory data
LV ejection fraction (%)* 58 (54-63) 58 (54-63) 0.959
tained at 20-to-30 cmH2O. Regarding oral hygiene, the nurses Hematocrit (%) 35 (32-39) 38 (35-42) < 0.001
swabbed sedated patients’ oral cavity three times daily using a C-reactive protein (mg/dL)* 0.15 (0.06-0.50) 0.14 (0.06-0.49) 0.585
rinse solution of 0.1% chlorhexidine gluconate. Awake Serum creatinine (mg/dL)* 0.90 (0.75-1.08) 0.90 (0.75-1.08) 0.734
patients gargled using the same solution. For postoperative Surgery/intraoperative profiles
Type of surgery 0.009
prophylaxis of stress ulcers, pantoprazole (40 mg) was admin- Coronary 694 (32.9%) 134 (28.6%)
istered intravenously or per os according to whether the patient Valve 861 (40.8%) 223 (47.6%)
could tolerate oral food intake. Thoracic aorta 144 (6.8%) 34 (7.3%)
Valve + coronary 46 (2.2%) 9 (1.9%)
Valve + thoracic aorta 169 (8.0%) 18 (3.8%)
Data Collection and Statistical Analysis Coronary + thoracic aorta 9 (0.4%) 2 (0.4%)
Coronary + valve + thoracic 19 (0.9%) 2 (0.4%)
Demographics, preoperative morbidities, medication his- aorta
Miscellaneous 166 (7.9%) 46 (9.8%)
tory, laboratory data, surgical profiles, and intraoperative Anesthesia time (min) 440 (380-505) 400 (340-450) < 0.001
records (Table 1) were retrieved from the electronic medical CPB use 1415 (67%) 307 (66%) 0.562
records. The development of postoperative VAP, the duration CPB time (on-pump, min) 195 (144-247) 165 (120-210) < 0.001
of postoperative mechanical ventilation, reintubation episodes, Redo surgery 190 (9.0%) 24 (5.1%) 0.008
Emergency surgery 220 (10.4%) 27 (5.8%) 0.003
tracheostomy, length of ICU stay, and in-hospital mortality IABP use 49 (2.3%) 14 (3.0%) 0.497
were collected as outcome variables. The Infection Control ECMO use 11 (0.5%) 2 (0.4%) > 0.999
Center of the authors’ institution is running a surveillance pro- Dobutamine use 1091 (51.8%) 246 (52.6%) 0.790
gram for VAP in all patients admitted to the ICU after cardiac Dopamine use 84 (4.0%) 10 (2.1%) 0.073
Epinephrine use 128 (6.1%) 33 (7.1%) 0.493
surgery. Postoperative VAP was identified according to the Norepinephrine use 1327 (63.0%) 353 (75.4%) < 0.001
National Healthcare Safety Network (NHSN) surveillance def- RBC transfusion (packs) 0 (0-2) 0 (0-2) 0.049
inition algorithm of the CDC, which is updated annually and
NOTE. Data are presented as mean (standard deviation), median (interquartile
can be accessed elsewhere (Supplementary Tables 1-5).10
range), or number (%).
The primary outcome was the risk of VAP after cardiac sur- Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB,
gery identified by the NHSN surveillance definition algorithm angiotensin II receptor blocker; COPD, chronic obstructive pulmonary
according to whether intraoperative continuous and subsequent disease; CPB, cardiopulmonary bypass; ECMO, extracorporeal membrane
postoperative intermittent SSD were implemented. The sec- oxygenation; IABP, intra-aortic balloon pump; RBC, red blood cell.
* There were 17, 20, and 5 missing values in left ventricular ejection frac-
ondary outcomes included reintubation episode, tracheostomy,
tion, C-reactive protein, and serum creatinine, respectively.
duration of mechanical ventilation, length of ICU stay, all-
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4 K. Nam et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2020) 18
cause in-hospital mortality, and VAP-specific in-hospital mor-
tality.
Continuous variables were expressed as means (standard
deviation) or medians (interquartile range) and were compared
among the groups with the independent t or Mann-Whitney U
test after checking the normality assumption with the Shapiro-
Wilk test. Categorical variables were presented as numbers
(%) and were analyzed by the chi-square or Fisher exact test,
as appropriate.
Considering the rarity of the events of interest, a weighted
logistic regression analysis of the primary outcome was per-
formed.11 The weights for observations were calculated as fol-
lows:
n Patient characteristics are summarized in Table 1. A history
wj ¼
knj
where wj is weight for class j, k is number of classes, n is number
of observations, and nj is number of observations in class j.11 All
potential confounders listed in Table 1 were adjusted for without
variable selection. The duration of cardiopulmonary bypass was
categorized into tertiles before analysis because of its multicolli-
nearity with the duration of anesthesia. For missing data (C-reac-
tive protein level [n = 20]; left ventricular ejection fraction
[n = 17]; and serum creatinine level [n = 5]), sex-specific medians
were substituted. A propensity score analysis was performed to
match patients in the two groups using the covariates pre-
viously described. The nearest-neighbor matching method
was used with a ratio of 1:3 because of the substantially
reduced number of cases and rare events. After matching, a
second multivariate weighted logistic regression was per-
formed. In addition, an additional multivariate logistic
regression, with inverse probability weighting to adjust for
the propensity score, was conducted.12-14
Fig 2. Flow diagram of the study.
Statistical analysis was performed using R software, Ver-
sion 3.6.1 (R Development Core Team, Vienna, Austria). A p
value < 0.05 was considered to be indicative of statistical sig-
nificance.
Results
A total of 2,840 patients underwent cardiac surgery during
the study period. Among them, 264 patients were excluded,
and the remaining 2,576 were analyzed (Fig 2). Conventional
and subglottic suctioning endotracheal tubes were used in the
control (n = 2,108) and intervention groups (n = 468), respec-
tively.
of smoking, cerebrovascular disease, and myocardial infarc-
tion was more common in the intervention group than in the
control group. A history of preoperative myocardial infarction
and chronic kidney disease was less common and the duration
of surgery and cardiopulmonary bypass were shorter in the
intervention group than in the control group.
Overall, VAP after cardiac surgery, defined using the CDC/
NHSN surveillance definition algorithm, was identified in 31
patients (1.2%). The incidence density was 5.8 episodes per
1,000 ventilator-days. VAP occurred a median of three days
(interquartile range two-five days ) after cardiac surgery. A
pathogenic microorganism was isolated from nine patients in
the control group and none in the intervention group. Klebsi-
ella pneumoniae was the most common pathogen (six iso-
lates), followed by Escherichia coli (2two isolates) and
Hemophilus influenzae (one isolate).
Postoperative VAP was less common in the intervention
group compared with the control group (1/468 [0.2%] v 30/
2,108 [1.4%] (Fig 3, A). The incidence density of VAP also
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K. Nam et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2020) 18 5

Fig 3. (A) The incidence and (B) the incidence density of ventilator-associated pneumonia after cardiac surgery according to the study groups. SSD, subglottic
secretion drainage; VAP, ventilator-associated pneumonia.

was lower in the intervention group than in the control group
(1.2 v 6.6 episodes per 1,000 ventilator-days (Fig 3, B). The
median (interquartile range) length of ICU stay was 13 (10-30)
and two (one-four) days in patients who developed VAP and
those who did not, respectively. In-hospital mortality was
29.0% (9/31) and 2.5% (63/2,545) in patients with and without
VAP, respectively.
In the multivariate weighted logistic regression model, the
risk of VAP after cardiac surgery was significantly lower in
patients who underwent perioperative SSD compared with
those who did not (adjusted odds ratio 0.29; 95% confidence
interval 0.14-0.5; p < 0.001) (Table 2). Similar results were
obtained in the propensity score-matched cohort. The matched
cohort comprised 468 and 1,404 patients in the intervention
and control groups, respectively. In the multivariate weighted
logistic regression analysis of the matched cohort, the risk of
postoperative VAP was significantly lower in the intervention
group than in the control group (adjusted odds ratio 0.04;
95% confidence interval 0.01-0.14; p < 0.001) (see Table 2).
In addition, a multivariate logistic regression analysis, with
inverse probability weighting, revealed a significantly
decreased risk of postoperative VAP in patients in the inter-
vention group (adjusted odds ratio 0.16; 95% confidence inter-
val 0.05-0.42; p < 0.001).
The secondary outcomes are listed in Table 3. The duration
of mechanical ventilation was similar between the two groups
(median [interquartile range] 17.5 [12.5-34.8] h v 17.0 [12.0-
23.3] h; p = 0.064). In addition, rates of reintubation, tracheos-
tomy, and all-cause in-hospital mortality were similar in the
two groups. The median and the interquartile range of length
of ICU stay were the same in the two groups (two [one-four]
d), although the difference of the rank sum was statistically
significant in the nonparametric test (p = 0.009). Of the 30
patients who developed postoperative VAP in the control
group, nine patients (30.0%) died during the hospital stay,
among whom five patients (16.7%) died from VAP. One
patient who developed VAP in the intervention group was dis-
charged alive from the hospital. However, the difference in

Table 2
Logistic Regressions for Ventilator-Associated Pneumonia After Cardiac Surgery

Total Study Cohort Propensity Score Matched Cohort Inverse Probability Weighting
Unadjusted OR p Value Adjusted OR (95% CI)* p Value Adjusted OR p Value Adjusted OR (95% CI)* p Value
(95% CI) (95% CI)*

Study groups
No perioperative SSD 1.00 (Reference) 1.00 (Reference) 1.00 (Reference) 1.00 (Reference)
Perioperative SSD 0.15 (0.11-0.21) < 0.001 0.29 (0.14-0.58) < 0.001 0.04 (0.01-0.14) < 0.001 0.16 (0.05-0.42) < 0.001

Abbreviations: CI, confidence interval; OR, odds ratio; SSD, subglottic secretion drainage.
* The multivariable models were adjusted for all variables listed in Table 1. The duration of cardiopulmonary bypass was categorized into tertiles before being
entered into the multivariable analyses due to its multicollinearity with anesthesia time.
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6 K. Nam et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2020) 18
Table 3
Comparison of Secondary Outcomes According to Study Group
Control Intervention
(n = 2,108) (n = 468)
Reintubation 134 (6.4%) 27 (5.8%)
Tracheostomy 51 (2.4%) 15 (3.2%)
Duration of 17.5 (12.5-34.8) 17.0 (12.0-23.3)
mechanical
ventilation (h)
Length of 2 (1-4) 2 (1-4)
intensive care
unit stay (d)
In-hospital 56 (2.7%) 16 (3.4%)
mortality
NOTE. Data are presented as number (%) or median (interquartile range).
VAP-specific in-hospital mortality between the groups did not
reach statistical significance (5/2,108 [0.2%] v 0/486 [0.0%];
p = 0.592; data not shown in Table 3).
Discussion
In this before-and-after, retrospective, cohort study, the
implementation of routine use of subglottic suctioning endo-
tracheal tubes was significantly associated with a marked
reduction in the frequency of VAP after cardiac surgery. After
adjusting for numerous potential confounders, there was a
70% relative reduction in the rate of postoperative VAP in
patients who underwent intraoperative continuous and postop-
erative intermittent SSD using a subglottic suctioning endotra-
cheal tube, compared with those who did not. Indeed, greater
effects were identified in multivariate analyses after propensity
score matching and inverse probability weighting.
Because mechanical ventilation is continued postoperatively
in the majority of patients undergoing cardiac surgery, postop-
erative VAP is of particular concern—the incidence is report-
edly more than 6% and the incidence density is 13.9-to-22.2
episodes per 1,000 ventilator-days.1,15,16 To prevent VAP, a
so-called “ventilator bundle,” which consists of head eleva-
tion, oral hygiene, hypopharyngeal suctioning, prophylactic
antibiotics, and daily awakening/breathing trial, has become
routine practice in patients receiving mechanical ventilation.17
Nonetheless, there are no convincing results showing that a
bundled strategy can reduce VAP rates,18 which is in line
with the absence of significant reduction in VAP rates
from 2005 through 2013.19 Meanwhile, management related
to an endotracheal tube has not been the main concern in
terms of preventing VAP. In the present study, periopera-
tive SSD using a commercially available endotracheal tube
with an embedded suction channel was significantly associ-
ated with a decreased risk of VAP after cardiac surgery.
Leakage of contaminated secretions in the subglottic space
past the endotracheal tube cuff is a principal cause of VAP.20
Aspiration of subglottic secretions, however, cannot be pre-
vented using conventional high-volume, low-pressure cuffs
irrespective of whether the cuff pressure is adequately main-
tained3 because secretions pass through the micro-channeled
folds that form on the surface upon cuff inflation.21 Because of
this issue, there have been several trials to prevent VAP by
p Value
simply modifying the cuff design, but a specially designed
endotracheal tube with a tapered cuff, which was the most
promising, failed to prevent microaspiration and VAP.22
0.635 Mahul et al.23 were the first to suggest SSD using a subglot-
0.330
0.064
tic suctioning endotracheal tube for the prevention of VAP in
1992. Numerous studies supporting SSD have followed,4,6 but
its application is not yet routine. Although it was recom-
0.009 mended in the CDC (category II)5 and the American Thoracic
Society/Infectious Disease Society of America guidelines
0.365
(level I),24 only 20% of ICUs in North America in 2008 and
50% of ICUs in the United Kingdom in 2015 were performing
SSD as part of the ventilator bundle.25,26 Indeed, one European
bundle does not recommend the routine use of SSD.27 These
are partly because of disagreement about the strength of previ-
ous evidences supporting the use of SSD among clinicians.25
There are varying opinions of clinicians about existing eviden-
ces supporting the use of SSD, and it still is regarded as a con-
troversial method for the prevention of VAP.25 Therefore,
additional studies are required to obtain sufficient evidence.
Furthermore, almost all prior studies were performed in criti-
cally ill patients4,6; the three that focused on cardiac surgery
yielded inconsistent results.7-9 Bouza et al.7 reported that the
use of continuous SSD in cardiac surgery patients on postoper-
ative mechanical ventilation for more than 48 hours decreased
the incidence and the incidence density of VAP. The most
recent study, by Gopal et al.,8 showed a significant reduction
in VAP after cardiac surgery using intermittent SSD. In con-
trast, Kollef et al.9 found no significant difference in the inci-
dence of VAP after cardiac surgery in patients who underwent
continuous SSD compared with those who received routine
postoperative care. In the present study, intraoperative contin-
uous SSD, accompanied by postoperative intermittent SSD,
demonstrated the prevention of VAP after cardiac surgery. To
the authors’ knowledge, no study has assessed the effect of
intraoperative SSD in addition to postoperative SSD. All of
the aforementioned prior studies evaluated the effect of post-
operative SSD alone. Given the relatively long duration of car-
diac surgery, the potential effect of intraoperative mechanical
ventilation on the development of postoperative VAP should
not have been overlooked.
SSD can be applied intermittently or continuously; however,
it is unclear which is superior.28 Also, the safety of (continu-
ous) SSD is not well-established, and several animal studies
and case reports have indicated a risk of tracheal mucosal
injury with SSD.29,30 Bouza et al.7 reported no complica-
tions related to SSD, with a continuous negative pressure
of 100-to-150 mmHg in a randomized clinical study,
whereas mucosal/submucosal injury of the trachea occurred
at a low continuous negative pressure of 20 mmHg in an
animal study29 and at <20 cmH2O in case reports.30 In the
present study, a continuous negative pressure of
20 mmHg was used for intraoperative SSD via wall suc-
tion according to the manufacturer’s instructions; no tra-
cheal injury occurred during surgery or postoperatively
when intermittent SSD was applied.
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K. Nam et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2020) 18
Because of concern about aspiration of secretions, in the
present study, subglottic suctioning was performed with a high
negative pressure for a short time immediately before with-
drawal of the transesophageal echocardiography probe at the
end of surgery. However, frequent manipulation of the probe
during surgery can cause endotracheal tube malpositioning,
although it is very rare (0.03%).31 In this case, SSD may be
not effective as well. Additional studies on this topic are
required.
The present study had several limitations. First, it was of a
retrospective design. Although numerous potential confound-
ers were adjusted for in the multivariate regression, the results
may have been biased to some extent. To offset any bias, a
multivariate analysis was conducted in the matched cohort,
and another multivariate logistic regression with inverse prob-
ability weighting was performed to overcome the limitations
of propensity score matching.12-14 The before-and-after analy-
sis of a prospectively implemented policy in a single center
also may have reduced the bias. Second, the NHSN surveil-
lance definition algorithm of the CDC was used to define
VAP, which was not based on a physician’s definitive clinical
decision. The incidences of VAP and its density likely were
underestimated or overestimated in the present analysis. How-
ever, challenges remain in the definitive clinical diagnosis of
VAP, which can have various clinical manifestations and be
caused by diverse pathogens.1 Moreover, several modifications
have been made to the NHSN surveillance definition algorithm
on an annual basis since it was developed in January 2013,
and, thus, the definition of VAP could not be applied uniformly
in this study. Third, the event rate of VAP was so low that the
study cohort might have been somewhat imbalanced for a mul-
tivariate analysis. Although a weighted logistic regression was
used,11 this issue still may exist. Fourth, the duration of post-
operative mechanical ventilation was fairly long in patients of
this study. Enhanced recovery after surgery programs, includ-
ing a fast-track extubation protocol, were initiated in the
authors’ center after this study. It is not known whether periop-
erative SSD also is beneficial during the programs. Fifth, this
study did not assess whether intraoperative SSD had an addi-
tive effect on the prevention of VAP when accompanied by
postoperative SSD. Prospective randomized trials comparing
intraoperative and postoperative SSD with postoperative SSD
alone are required. Sixth, the reduction of VAP incidence did
not result in a statistically significant improvement in clinical
outcomes, such as postoperative mortality (particularly, VAP-
specific death), in this study. The incidence of VAP-specific
mortality was 0.2% (5/2,576) in this study. Based on this inci-
dence, a minimum sample size of 6,664 is required to detect
the difference in VAP-specific mortality using the Fisher exact
test with a power of 0.8 (while assuming VAP-specific mortal-
ity of 0% in the intervention group, although unrealistic). This
number is much larger than the number of patients analyzed in
the present study. This means that the results of the present
study may not exclude the possibility of clinical benefit from
routine use of subglottic suctioning endotracheal tubes in
patients undergoing cardiac surgery. In addition, clinical out-
come of routine use of subglottic suctioning endotracheal
7
tubes may not be easy to evaluate in future clinical trials
because a very large sample size is required. Furthermore, if
subglottic suctioning endotracheal tubes also had been used in
the control group (n = 2,108) as in the intervention group (in
which one of 468 patients developed VAP), there would have
been 5.5 cases of VAP (instead of 31) and nearly no VAP-spe-
cific death (instead of five). This means that routine periopera-
tive use of subglottic suctioning endotracheal tubes might
have saved five patients.
Conclusion
In conclusion, this retrospective analysis demonstrated that
routine use of subglottic suctioning endotracheal tubes may
reduce the risk of postoperative VAP in patients undergoing
cardiac surgery. The risk of postoperative VAP was signifi-
cantly lower in patients who received intraoperative continu-
ous and postoperative intermittent SSD compared with those
who did not.
Acknowledgments
This study used clinical data retrieved from the Seoul
National University Hospital Patients Research Environment
system.
Conflict of Interest
The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper.
Supplementary materials
Supplementary material associated with this article can be
found in the online version at doi:10.1053/j.jvca.2020.09.126.
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