A randomized study assessing the systematic search for maxillary sinusitisin nasotracheally mechanically ventilated patients - Influence of nosocomial maxillary sinusitis on the occurrence of ventilator-associated pneumonia

The objective of this randomized study was to compare the occurrence of nos ocomial pneumonia in nasotracheally intubated patients who were randomly al located either to a systematic search of sinusitis by CT scan (study group) or not (control group). A total of 399 patients were included: 272 male an d 127 female; mean age, 61 +/- 17 yr; SAPS: 12.6 +/- 4.9. The study group c onsisted of 199 patients and the control group consisted of 200. In the stu dy group, sinus CT scans were performed in case of fever at Days 4 and 8 an d then every 7 d. Nosocomial sinusitis was defined as follows: fever of gre ater than or equal to 38 degrees C, radiographic (sinusal air-fluid level o r opacification on CT scan) signs, and presence of purulent aspirate from t he involved sinus puncture with greater than or equal to 10(3) cfu/ml. Pati ents with sinusitis received sinus lavage and intravenously administered an tibiotics. In the study group, 80 patients experienced nosocomial sinusitis . In the control group, no patient was treated for a sinusitis. Ventilator- associated bronchopneumonia (VAP) was observed in 88 patients: 37 in the st udy group (1 mo Kaplan-Meier estimate, 34%) versus 51 in the control group (1 mo Kaplan-Meier estimate, 47%); (p = 0.02, log-rank test; relative risk [RR] = 0.61; 95% confidence interval [CI], 0.40 to 0.93). Two months overal l mortality was estimated at 36% in the study group versus 46% in the contr ol group (p = 0.03, log-rank test; RR = 0.71; 95% CI, 0.52 to 0.97). We con clude that the occurrence of VAP in patients undergoing prolonged mechanica l ventilation via a nasotracheal intubation can be prevented by the systema tic search and treatment of nosocomial sinusitis. The effect on mortality s hould be confirmed.