INFLUENCE OF LONG-TERM OROTRACHEAL OR NASOTRACHEAL INTUBATION ON NOSOCOMIAL MAXILLARY SINUSITIS AND PNEUMONIA - RESULTS OF A PROSPECTIVE, RANDOMIZED, CLINICAL-TRIAL

Objective. To compare the occurrence rate of nosocomial maxillary sinu sitis and pneumonia in patients who have undergone nasotracheal vs. or otracheal intubation. Design: Randomized, clinical trial. Setting. Gen eral adult intensive care unit (ICU) in a nonteaching public hospital. Patients: A total of 300 (209 male, 91 female) patients were included . The mean age was 59 +/- 17 (SD) yrs. The simplified acute physiologi c score was 14 +/- 6. Reasons for admission to the ICU were: coma (n = 78), pneumonia (n =46), infection (n =35), surgery (n = 34), multiple trauma (n =20), head trauma (n =12), other (n =75). Among the 300 pati ents, 149 were randomized into the nasotracheal group and 151 into the orotracheal group. No statistical difference was found between initia l characteristics of the two groups. Interventions: Patients were rand omized between nasal and oral endotracheal intubation. Gastric intubat ion was performed via the same route as endotracheal intubation. Sinus computed tomography (CT) scans were performed every 7 days or earlier in case of fever and/or purulent nasal discharge. Criteria for nosoco mial sinusitis were as follows: fever of >38-degrees-C, radiographic ( sinusal air-fluid level or opacification on CT scan) signs and presenc e of purulent aspirate from the involved sinus puncture with 10(3) col ony-forming units (cfu)/mL. Diagnosis of pneumonia was based on classi cal criteria and a protected brush specimen with 10(3) cfu/mL. Measure ments and Main Results: Radiographic evidence of sinusitis was observe d in 78 patients, 45 from the nasal group and 33 from the oral group ( p =.08, log-rank test). Among these patients, 54 fulfilled the sinusit is criteria stated above, 29 in the nasal group and 25 in the oral gro up (p =.75, log-rank test). Nosocomial pneumonia was observed in 26 pa tients, 17 in the nasal group and 9 in the oral group (p =.11, log-ran k test). A multivariable analysis considering sinusitis as a time-depe ndent factor has suggested that sinusitis increased the risk of nosoco mial pneumonia by a factor of 3.8. Nosocomial septicemia was observed in 33 patients, 22 episodes in the nasal group and 13 episodes in the oral group (p =.11, log-rank test). Overall mortality rate was 37% in the nasal group vs. 41% in the oral group (p =.37, log-rank test). Epi sodes of atelectasis and accidental extubations, and doses of sedative drugs and antibiotics were not different between the two groups. Leng th of mechanical ventilation did not differ between the two intubation groups. The mean length of stay in the ICU was 11 +/- 15 days in the nasal group vs. 9.5 +/- 11 days in the oral group (p =.27, Student's t -test). Conclusions. In patients undergoing prolonged mechanical venti lation, there was no statistically significant difference in the occur rence rate of nosocomial sinusitis or pneumonia between patients under going tracheal intubation via the nasal vs. oral route. A trend (p = 0 .08) suggests less sinusitis in the orotracheal group.