Impact of nutrition route on microaspiration in critically ill patients with shock: a planned ancillary study of the NUTRIREA-2 trial

Saad Nseir, Amélie Le Gouge, Jean-Baptiste Lascarrou, Jean-Claude Lacherade, Emmanuelle Jaillette, Jean-Paul Mira, Emmanuelle Mercier, Pierre-Louis Declercq, Michel Sirodot, Gaël Piton, François Tinturier, Elisabeth Coupez, Stéphane Gaudry, Michel Djibré, Didier Thevenin, Jeremy Pasco, Malika Balduyck, Farid Zerimech, Jean Reignier, Saad Nseir, Amélie Le Gouge, Jean-Baptiste Lascarrou, Jean-Claude Lacherade, Emmanuelle Jaillette, Jean-Paul Mira, Emmanuelle Mercier, Pierre-Louis Declercq, Michel Sirodot, Gaël Piton, François Tinturier, Elisabeth Coupez, Stéphane Gaudry, Michel Djibré, Didier Thevenin, Jeremy Pasco, Malika Balduyck, Farid Zerimech, Jean Reignier

Abstract

Background: Microaspiration of gastric and oropharyngeal secretions is the main mechanism of entry of bacteria into the lower respiratory tract in intubated critically ill patients. The aim of this study is to determine the impact of enteral nutrition, as compared with parenteral nutrition, on abundant microaspiration of gastric contents and oropharyngeal secretions.

Methods: Planned ancillary study of the randomized controlled multicenter NUTRIREA2 trial. Patients with shock receiving invasive mechanical ventilation were randomized to receive early enteral or parenteral nutrition. All tracheal aspirates were collected during the 48 h following randomization. Abundant microaspiration of gastric contents and oropharyngeal secretions was defined as the presence of significant levels of pepsin (> 200 ng/ml) and salivary amylase (> 1685 UI/ml) in > 30% of tracheal aspirates.

Results: A total of 151 patients were included (78 and 73 patients in enteral and parenteral nutrition groups, respectively), and 1074 tracheal aspirates were quantitatively analyzed for pepsin and amylase. Although vomiting rate was significantly higher (31% vs 15%, p = 0.016), constipation rate was significantly lower (6% vs 21%, p = 0.010) in patients with enteral than in patients with parenteral nutrition. No significant difference was found regarding other patient characteristics. The percentage of patients with abundant microaspiration of gastric contents was significantly lower in enteral than in parenteral nutrition groups (14% vs 36%, p = 0.004; unadjusted OR 0.80 (95% CI 0.69, 0.93), adjusted OR 0.79 (0.76, 0.94)). The percentage of patients with abundant microaspiration of oropharyngeal secretions was significantly higher in enteral than in parenteral nutrition groups (74% vs 54%, p = 0.026; unadjusted OR 1.21 (95% CI 1.03, 1.44), adjusted OR 1.23 (1.01, 1.48)). No significant difference was found in percentage of patients with ventilator-associated pneumonia between enteral (8%) and parenteral (10%) nutrition groups (HR 0.78 (0.26, 2.28)).

Conclusions: Our results suggest that enteral and parenteral nutrition are associated with high rates of microaspiration, although oropharyngeal microaspiration was more common with enteral nutrition and gastric microaspiration was more common with parenteral nutrition.

Trial registration: ClinicalTrials.gov, NCT03411447 . Registered 18 July 2017. Retrospectively registered.

Keywords: Critical care; Gastric contents; Microaspiration; Oropharyngeal secretions; Pathophysiology; Pneumonia.

Conflict of interest statement

Ethics approval and consent to participate

The study protocol was approved by the ethics committee of the French Intensive Care Society and appropriate French authorities (Comité de Protection des Personnes de Poitiers). According to French law, because the treatments and strategies used in the study were classified as standard care, there was no requirement for signed consent, but the patients or next of kin were informed about the study before enrolment and confirmed this fact in writing.

Consent for publication

Not applicable

Competing interests

FT received grants from Baxter, Nutricia, and Aguettant outside the submitted work. The other authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Study flowchart
Fig. 2
Fig. 2
Impact of nutrition route on abundant microaspiration of gastric contents and oropharyngeal secretions. *Adjusting for tracheal tube size and opioid use at admission

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