Anaesthesia, 1992, Volume 47, page 335-339

Nosocomial sinusitis in ventilated patients Nasotracheal versus orotracheal intubation

A. BACH, H . BOEHRER, H. SCHMIDT AND H. K. GEISS

Summary A total of 68 postoperative patients whose lungs were ventilated for more than 4 days were studied prospectively during a one-year study period to investigate the effect of the mode of intubation on the paranasal sinuses. After an initial X ray of the skull showing no pathologicaljndings, patients were assigned randomly to one of the study groups; the lungs of patients in group A were ventilated via an orotracheal tube ( n = 32), and patients in group B via a nasotracheal tube ( n = 36). X ray examinations of the sinuses were performed at regular intervals. Diagnosis of sinusitis was confirmed by transantral needle puncture and culture offluids obtained. Antibiotic regimens were altered according to laboratory testing. Two patients in group A developed signs of sinusitis in comparison to 15 patients in group B ( p < 0.01). However, there were significantly more airway complications in the orotracheal group, particularly during the period of weaning from ventilation. We conclude that orotracheal intubation should be preferred as the routine route of intubation. Key words Equipment; tubes, tracheal, tracheostomy. Intubation; tracheal. Complications; nosocomial infection, sinusitis. Nasotracheal intubation is often preferred to orotracheal intubation in patients who require long-term ventilation because of easier fixation of the tube and improved oral hygiene. Although there are many studies investigating the laryngotracheal complications due to nasotracheal intubation [ 1-91, recent concern has focused on paranasal problems [ 10-3 I]. Paranasal sinusitis during mechanical ventilation has been found to be an important cause of nosocomial infection and a source of sepsis [ 1 I , 171. The aim of our study was to compare the incidences of sinusitis associated with orotracheal and nasotracheal intubation. In addition, the frequency of complications associated with each route of intubation was investigated.

Patients and methods Study groups During the one-year study period from 1 October 1989, 68 patients who required mechanical ventilation in the postoperative Intensive Care Unit (ICU) of the Department of Anaesthesiology, University of Heidelberg, were included in this prospective study. Approval by the local ethics committee was obtained before the beginning of the study. Patients were not studied, if, on admission, they

presented any pathological radiological findings in the sinuses e.g. due to trauma, if they showed any sign of infection, if they were under 18 years of age, or if they received immunosuppressive drugs, and, later on, if their lungs were ventilated mechanically for less than 4 days. Patient care followed the normal protocol of our institution. All patients were transferred from the operating theatre to the ICU with a n oral tube in place. Study patients were then allocated randomly to one of two groups. In group A, orotracheal intubation (OT, internal tube diameter 8 mm, Rusch Co., Waiblingen, Germany) was continued. In group B, nasotracheal intubation (NT, internal tube diameter 7.5 mm, Rusch Co., Waiblingen, Germany) was achieved within 6 h of admission. Before nasotracheal insertion of the low pressure-high volume cuffed tube, the naso- and oropharyngeal cavity was flushed completely with a solution of beta-iodine (Braunol, Braun Co., Melsungen, Germany). Thereafter, 5 ml of 0.1 % oxymetazoline hydrochloride (Nasivin, Merck Co., Darmstadt, Germany) was injected into each nostril to induce vasoconstriction and to reduce local bleeding. Tubes were not changed routinely after primary insertion. All patients had a nasogastric tube in place for enteral feeding following surgery.

A. Bach, MD, H. Boehrer, MD, DEAA, Senior Registrars, H. Schmidt, MD, Registrar, Department of Anaesthesiology, University of Heidelberg, I N F 1 10, D-6900 Heidelberg, Germany, H.K. Geiss, M D , Senior Registrar, Institute of Hygiene. University of Heidelberg, I N F !3 324, D-6900 Heidelberg, Germany. Accepted 17 September 199I . 0003-2409/92/040335

+ 05 $03.00/0

@ 1992 The Association of Anaesthetists of G t Britain and Ireland

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A . Bach et al. Table I. Study population. Data are presented as mean (SD) or percentage of total in group.

Diagnostic procedures

Screening for sinusitis was carried out in all patients with the help of bedside antero-posterior X ray examination of the skull (‘reversed’ Waters’ view) on admission, on the 4th, 7th and 10th postoperative days and thereafter at weekly intervals. The X rays were evaluated by an experienced radiologist who was not involved in this study. Patients were examined according to the standard procedures of our department until discharge from the ICU or death. All the patients were followed routinely for clinical evidence of infection. Patients who developed signs of infection with no apparent source were submitted to thorough diagnostic investigations including a CT scan of the head (Fig. 1). Diagnosis of sinusitis was suspected if the X ray examination showed opacification of the sinuses or air-fluid levels. Diagnosis of sinusitis was made if there were positive radiological signs associated with infection e.g. leukocytes > 15 x I O 9 . l - ’ and fever > 38.5”C, and confirmed by transantral maxillary sinus needle puncture with subsequent culture of at least one pathological micro-organism. Culture of the fluid recovered by transantral puncture and drainage was performed and pathogens identified according to standard microbiological procedures. Therapeutic approach

If purulent sinusitis was present, the sinus was drained by insertion of a silicone tube in the inferior meatus, and a tracheostomy was performed if the patient showed persistcnt signs of infection within 24 h. Results were compared using the Chi-squared test with Yates’ correction. A p value of < 0.01 was considered to be significant.

Mechanical ventilation; days Stay in ICU; days SAPS Age; years Sex; male/female Mortality

Patients in groups A and B were similar in respect of age, sex, severity of illness (Simplified Acute Physiological Score

Group B “TI (n = 36)

12.1 (9.5) 16.8 (8.3) 12 (4.5) 62.8 (10.7) 24/8 3 1.2%

10.9 (8.7) 15.2 (7.5) 13 (3.5) 65.1 (9.8) 28/8 27.7%

OT, orotracheal intubation: NT, nasotrdcheal intubation; SAPS, Simplified Acute Physiological Score.

(SAPS) [32]), duration of mechanical ventilation, stay in the ICU and mortality (Table 1). Rate of nosocomial sinusitis

During the observation period 15 patients in group A (orotracheal intubation) and 25 patients in group B (nasotracheal intubation) developed radiological signs of sinus infection. A suspected diagnosis was confirmed by sinus needle aspirate and culture in two patients in group A and 15 in group B (p < 0.01, Chi-squared analysis; Table 2 and Fig. 2).

Table 2. Incidence of sinusitis.

Results Patient characteristics

Group A (OT) (n = 32)

Positive radiological findings Sinusitis

Group A (OT

Group B

(n = 32)

(n

46.8% 6.3%

For abbreviations see Table I .

without infection

I

I

Orotracheal intu bation

investigations

-+

Drains systemic antibiotics Persistent infection >24 h

I

x ray of sinuses on days 0.3,7. 10. I?, 24...

I Tracheostomy

4

Positive

Sinus needle aspiration and culture

Negative

Resolution of infection

1

Fig. 1. Flow chart showing plan of investigations and treatment of patients who entered the study.

W“ =

36)

69.4% 4 I .6%

Nosocomial sinusitis in ventilated patients 50

-

Bacteriological findings NT

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.-

30-

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337

2010-

I

OT

I

In the orotracheal group, the two cases of sinusitis occurred on the side of insertion of a nasogastric tube. In the nasotracheal group, 10 of the 15 cases were found to be on the side of nasotracheal intubation, two were on the side of the nasogastric tube, and three were bilateral. In group A, the maxillary sinuses were affected in both patients. The involvement of the sinuses in group B is shown in Table 3.

Tracheal aspirates were obtained in all patients twice a week. Culture and identification of isolated micro-organisms followed standard microbiological methods. Sinus aspirates were obtained in 40 patients who showed abnormal X ray findings. The procedure was performed under sterile conditions after cleansing the anterior nasal cavity with povidone-iodine solution to avoid contamination. In 17 cases the fluid was found to be purulent, and

Incidents related to ventilation

Six incidents which required emergency treatment occurred in the orotracheal group, all during the period of weaning from the ventilator; self-extubation required immediate reintubation in three patients, unilateral bronchial intubation with subsequent atelectasis occurred in two patients and

Table 3. Site of sinus involvement in patients with sinusitis Group A (OT) Group B (NT) Maxillary sinus Frontal sinus Maxillary and frontal sinuses Ethmoid, maxillary and frontal sinuses Sphenoidal, maxillary and frontal sinuses

2 0

7 2 4

0 0 0

I* I*

* Results of CT scans. For abbreviations see Table I. Table 4. Micro-organisms isolated from sinus and tracheal aspirates. Sinus

Trachea

Orotracheal tube Patient 1 Patient 2"

Ps. aeruginosa Staph. aureus

Ps. aeruginosa Staph. aureus

Nasotracheal tube Patient I** Patient 2** Patient 3 Patient 4

Ps. aeruginosa Staph , epidermidis Morganella marganii E. coli

Ps. aeruginosa Sterile Ps. maltophilia' E. coli Klebsiella pneumoniae Citrobacter Ps. aeruginosa

Patient 5 Patient 6** Patient 7**

Citrobacrer A cinetobacter Ps. aeruginosa Enterococcus

Patient 8

Candida albicans'

Patient 9** Patient 10 Patient I I

Ps . aeruginosa Ps. maliophilia*

Patient Patient Patient Patient

12** 13'* 14

15

Serratia marcescens Klebsiella oxytoca Acinetobacler Staph. epiderm idis Candida albicans'

Enterococcus Staph. epidermidis Candida albicans* Staph. epidermidis Sterile P.F.malfophilia' Serratia marcescens Ps. aeruginosa Klebsiella oxytoca Acinerobacter Enterococcus* Candida albicans' Staph. aureus

~

* Not sensitive to the antibiotic given at time of diagnosis. ** Patients not treated with systemic antibiotics a t the time of diagnosis.

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A . Bach et al.

hypoxaemia occurred in one patient who bit the tracheal tube. One patient in group B suffered extubation due to inadequate fixation. The frequency of incidents was significantly higher in the orotracheal than the nasotracheal group. Response to therapy

In 13 patients with confirmed diagnosis of sinusitis, symptoms resolved after orotracheal intubation, systemic antibiotic treatment, and local irrigation with sterile saline via sinus drains. Tracheostomy led to the resolution of infective symptoms in two patients in group B. In two other patients in group B, the same organism was isolated in tracheal aspirate and peripheral blood. These two septic patients recovered from this episode, one after tracheostomy was performed because of nasal ulceration. In all other patients, blood cultures remained negative despite clinical signs of septicaemia in some patients. Ten patients in each group died of other causes such as multiple organ failure in the later course of the ICU stay.

Discussion In patients receiving long-term mechanical ventilation, nosocomial sinusitis is a serious but underestimated complication which is associated particularly with prolonged nasotracheal intubation [ 10-3 11. The incidence ranges from 100% [22] to 1.4% [23] according to the patient population and the definition of sinusitis. Sinusitis may lead to severe complications, e.g. meningitis, pneumonia and septicaemia [19,25,26]. Under normal conditions, the maxillary sinuses are sterile and well drained by constant mucociliary activity. Obstruction of the ostia due to local swelling may predispose to mucosal oedema, retention of secretions and infection. Occlusion of the sinus openings and blockage of sinus outflow through the nasal ostia by a large-bore tracheal tube is thought to be a main pathogenic factor for sinusitis in ICU patients [23,33,34]. Thus, either the normal flora of the sinuses or colonising hospital-acquired organisms become pathogenic. In the ventilated and sedated patient, the usual clinical symptoms of sinusitis (e.g. facial pain, headache and local swelling) are frequently absent. Purulent nasal discharge may be a leading symptom. The diagnosis can be made only by a combination of radiological examination (bedside radiography, C T scan), microbiological cultures, and clinical symptoms of infection [30,34-371. Radiological signs of sinusitis (mucosal thickening, opacification of the spaces, or air-fluid levels in the sinus cavity) are nonspecific and a common finding in mechanically ventilated patients irrespective of the mode of intubation [35,36]. These signs d o not necessarily imply a bacterial infection of the sinus cavity although radiographic signs of mucus retention may be precursors of infection [24,27,34]. The same applies to ultrasound examination of the sinuses; findings suggesting sinusitis are found in over 60% of all intubated patients [20,30,31]. The reversed Waters’ view seems to be adequate for the diagnosis of maxillary sinusitis [26,35], with the maxillary cavities being affected in most cases [19]. CT scans are superior in the investigation of sinuses other than the maxillary or frontal, e.g. ethmoidal sinuses [ 19,27,37].

However, this procedure requires transportation of critically ill patients and this has inherent risks. Bacteriological samples could be contaminated by nasal flora. Cleaning the nares with a n antiseptic instillation before puncture and drainage may reduce this risk [ 121. In our patients, we observed colonisation and infection of the sinuses and the lungs mostly by the same micro-organisms. This finding confirms the findings of other authors [19,25,26]. The safe duration of tracheal intubation is difficult to define. Recent surveys show a wide variety of common practices and a growing tendency towards prolonged tracheal intubation for up to 3 weeks [9,38]. Late laryngeal lesions and incidents of airway problems are more common with orotracheal intubation. Nasotracheal intubation leads to a higher incidence of local bleeding, local trauma, ear infections, and bacteraemia. Fixation of an orotracheal tube requires meticulous attention to avoid pressureinduced sores and accidental extubation. The indication for prolonged nasotracheal intubation instead of orotracheal intubation and/or tracheostomy should be considered carefully [3-9,271. A suspected diagnosis of sinusitis (clinically or rddiologically) should be confirmed by puncture of the sinuses concerned and by subsequent culture of the aspirate [19,23,26]. The nasotracheal tube should then be changed in favour of an orotracheal tube. Subsequent surgical drainage should be performed, and some authors recommend tracheostomy [26,30]. Systemic antibiotic treatment should be initiated, or altered according to laboratory results [34]. In our department, nasotracheal intubation within 72 h after admission had been routine procedure for long-term mechanical ventilation. The trachea remained intubated for up to 4 weeks before a tracheostomy was considered. Our routine has now changed; patients who require mechanical ventilation for longer than 4 days are left with an orotracheal tube. Short-term nasotracheal intubation ( < 72 h) is performed only if there are adverse incidents during the weaning period. Otherwise, a tracheostomy is preferred. All nasal tubes should be removed and systemic antibiotics should be applied in any patient in whom sinusitis is diagnosed. Sinus drains are inserted and irrigated with a sterile solution of saline. Tracheostomy and surgical drainage of the sinuses are carried out only if the symptoms of infection persist for more than 24 h after changing to an oral tube.

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