Am. J. Respir. Crit. Care Med., Volume 159, Number 3, March 1999, 695-701

A Randomized Study Assessing the Systematic Search for Maxillary Sinusitis in Nasotracheally Mechanically Ventilated Patients
Influence of Nosocomial Maxillary Sinusitis on the Occurrence of Ventilator-associated Pneumonia

LAURENT HOLZAPFEL, CLAUDE CHASTANG, GUY DEMINGEON, JULIEN BOHE, BONAVY PIRALLA, and ALAIN COUPRY

Service de Réanimation et Service de Bactériologie, Centre Hospitalier, Bourg en Bresse; and Département de Biostastistique et Informatique Médicale, Hôpital Saint Louis, Paris, France

The objective of this randomized study was to compare the occurrence of nosocomial pneumonia in nasotracheally intubated patients who were randomly allocated 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 and 127 female; mean age, 61 ± 17 yr; SAPS: 12.6 ± 4.9. The study group consisted of 199 patients and the control group consisted of 200. In the study group, sinus CT scans were performed in case of fever at Days 4 and 8 and then every 7 d. Nosocomial sinusitis was defined as follows: fever of  38° C, radiographic (sinusal air-fluid level or opacification on CT scan) signs, and presence of purulent aspirate from the involved sinus puncture with  10³ cfu/ml. Patients with sinusitis received sinus lavage and intravenously administered antibiotics. 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 study 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 overall mortality was estimated at 36% in the study group versus 46% in the control group (p = 0.03, log-rank test; RR = 0.71; 95% CI, 0.52 to 0.97). We conclude that the occurrence of VAP in patients undergoing prolonged mechanical ventilation via a nasotracheal intubation can be prevented by the systematic search and treatment of nosocomial sinusitis. The effect on mortality should be confirmed.

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