Durante la realizzazione della revisione, non è stato possibile reperire alcuni articoli riguardanti la problematica del sistema di aspirazione perché erano a pagamento.
5.2 Discussione
Questa revisione della letteratura è composta 100 articoli, la loro provenienza geografica è soprattutto americana (Stati Uniti, Canada, Brasile) ed europea (Spagna, Inghilterra, Francia, Italia, Belgio, Grecia, Austria, Svezia, Paesi Bassi). La tipologia di essi è composta in maggior misura da studi clinici controllati randomizzati (RCT), da meta analisi e da revisioni.
Dall’analisi complessiva del lavoro effettuato emerge che, di questi 100 articoli, 38 trattano specificatamente il sistema di aspirazione per la prevenzione della VAP. Dall’osservazione di questi ultimi emerge che il 79% degli articoli afferma che non sussiste differenza fra l’utilizzo del sistema chiuso rispetto a quello aperto nell’incidenza della polmonite associata alla ventilazione meccanica, mentre il 21% sostiene che il più idoneo allo scopo sia il sistema chiuso.
La revisione si è focalizzata sulla differenza dei costi derivanti dalla procedura, sulla contaminazione ambientale e su quella incrociata tra pazienti, sulle variazioni emodinamiche e sulla durata della manovra. Inoltre ha analizzato quale sistema sia più favorevole in pazienti con specifiche patologie quali HIV, tubercolosi, epatite B, neonati prematuri, trapiantati di fegato e l’utilizzo dei sistemi nei paesi in via di sviluppo. In quest’ultima casistica si è effettuata l’analisi in rapporto all’aspetto economico e al sovraffollamento, problematiche primarie in queste zone.
Nell’esaminare gli articoli selezionati è emerso che il personale infermieristico ritiene il sistema di aspirazione chiuso più maneggevole, più veloce nell’esecuzione della manovra e più sicuro se utilizzato nei neonati pretermine, in quanto causa meno disturbi fisiologici. Rimane comunque in loro la preoccupazione che, mantenendo il catetere in sede, esso possa diventare culla di agenti patogeni con il rischio di autocontaminazione per i pazienti.
28
Gli studi però hanno dimostrato che quest’ultima affermazione non trova fondamento, visto che i due sistemi di aspirazione non hanno evidenziato differenza significative sull’insorgenza della VAP.
5.3 Conclusione
La revisione ha messo in evidenza l’importanza fondamentale della manovra di aspirazione per i pazienti ricoverati in Terapia Intensiva e sottoposti a ventilazione meccanica. È stato riscontrato che non vi è alcuna differenza tra i due sistemi di aspirazione per la prevenzione della polmonite associata alla ventilazione meccanica. In definitiva però non basta semplicemente scegliere il tipo di aspirazione per prevenire la VAP, ma bisogna che questa manovra, per riuscire a ottenere un piano di prevenzione il più possibile ottimale per il paziente, deve essere utilizzata simultaneamente ad altre procedure preventive (elevazione della testa del letto da 30 a 45 gradi, aspirazione subglottica, igiene giornaliera del cavo orale con clorexidina, interruzione quotidiana della sedazione, filtri e sistema di umidificazione passivo, intubazione orotracheale, profilassi contro la trombosi venosa profonda e ulcera gastrica, letti ruotanti).
La VAP non è una patologia nuova, ma la ricerca sui metodi ottimali di prevenzione risulta ancora oggi una questione aperta soggetta a ulteriori studi futuri.
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