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Pneumonia
attractive alternative for patients with acute exacerbations of chronic Aspiration, Body Position and Enteral Feeding
obstructive pulmonary disease or acute hypoxaemic respiratory Supine patient positioning may also facilitate aspiration, which may be
failure and for some immunosuppressed patients with pulmonary decreased by a semi-recumbent position. Using radioactive labelled
infiltrates and respiratory failure.
11–15
Therefore, NPPV should be used technetium instilled into the stomach, cumulative radioactive counts
whenever possible in selected patients with respiratory failure. of endotracheal secretions were found to be higher when patients
were placed in the supine position (0°) compared with a semi-
Reduced duration of intubation and mechanical ventilation may prevent recumbent position (45°).
38–39
One randomised trial demonstrated a
ventilator-associated pneumonia (VAP). Specific strategies have been reduction in the incidence of ICU-acquired HAP in patients treated in
recommended in order to reduce the duration of mechanical the semi-recumbent position compared with patients treated
ventilation, such as improved methods of sedation and the use of completely supine.
40
Infection in patients in the supine position was
protocols to facilitate and accelerate weaning.
2,3,16–18
These interventions strongly associated with the simultaneous administration of enteral
are dependent on adequate ICU staffing. In particular, it is nutrition. Therefore, intubated patients should be kept in the semi-
recommended that sedation be interrupted or reduced on a daily basis recumbent position (30–45°) rather than supine to prevent aspiration,
in order to avoid constant heavy sedation, and paralytic agents should especially when receiving enteral feeding.
be avoided as both of these factors can depress coughing and thereby
increase the risk of HAP.
16
The use of NPPV in order to facilitate difficult Enteral nutrition has been considered a risk factor for the
weaning may also reduce the incidence of VAP.
19,20
Re-intubation should development of HAP mainly because of an increased risk of
be avoided if possible, as it increases the risk of VAP.
21
aspiration of gastric contents.
4,41
However, its alternative –
parenteral nutrition – is associated with higher risks of catheter-
Attention to the specific type of endotracheal tube, its maintenance and related infections, complications of line insertions, higher costs and
the site of insertion may also be valuable. Orotracheal intubation loss of intestinal villous architecture, which may facilitate enteral
and orogastric tubes are preferred over nasotracheal intubation and microbial translocation. Although some experts have advised
nasogastric tubes in order to prevent nosocomial sinusitis and to reduce feeding critically ill patients enterally as early as possible, a strategy
the risk of VAP, although direct causality has not been proved.
4,22,23
of early enteral feeding was associated with a higher risk of VAP
compared with late administration.
42
Measures to reduce the likelihood of aspiration of oropharyngeal
bacteria around the endotracheal tube cuff and into the lower Seven studies have evaluated the risk of ICU-acquired pneumonia in
respiratory tract include limiting the use of sedative and paralytic patients randomised to either gastric or post-pyloric feeding. Although
agents that depress coughing and other protective mechanisms of none of the individual studies demonstrated significant differences,
the host, and maintaining an adequate inflation of the endotracheal post-pyloric feeding was associated with a significant 24% reduction
cuff pressure.
24,25
Continuous aspiration of subglottic secretions in ICU-acquired HAP in meta-analysis.
43
Overall, enteral nutrition is
through the use of a specially designed endotracheal tube has preferred over parenteral nutrition in order to reduce the risk of
reduced the incidence of early-onset VAP significantly in several complications related to central intravenous catheters and to prevent
reflux villous atrophy of the intestinal mucosa, which may increase the
risk of bacterial translocation.
4,5,42
Progression from colonisation to
Modulation of Colonisation by
tracheobronchitis and pneumonia
Oral Antiseptics and Antibiotics
Progression from colonisation to tracheobronchitis and pneumonia is
is a dynamic process and the ability to
a dynamic process and the ability to discern the different entities
discern the different entities depends on
depends on the specificity of diagnostic tools. Oropharyngeal
colonisation, either present on admission or acquired during ICU stay,
the specificity of diagnostic tools.
has been identified as an independent risk factor for the development
of ICU-acquired pneumonia caused by enteric Gram-negative bacteria
and Pseudomonas aeruginosa.
44
In a randomised trial, the use of the
studies and should be used if available.
26–28
In addition, the oral antiseptic chlorhexidine significantly reduced the rates of
endotracheal tube cuff pressure should be maintained higher than nosocomial infection in patients undergoing coronary artery bypass
20cm H
2
O in order to prevent leakage of contaminated secretions surgery.
45
However, its routine use is not recommended until more
around the cuff into the lower respiratory tract.
24,25
data become available.
VAP may also be related to colonisation of the ventilator circuit.
29
The Modulation of oropharyngeal colonisation by combinations of oral
frequency of ventilator circuit change does not affect the incidence of antibiotics – with or without systemic therapy – or by selective
HAP, but condensate collecting in the ventilator circuit can become digestive decontamination (SDD) is also effective in significantly
contaminated from patients’ secretions.
24,30–33
Therefore, the inadvertent reducing the frequency of HAP, although the methodological quality of
flushing of the contaminated condensate into the lower airway or the study appears to be inversely related to the magnitude of the
nebulisers should be avoided by careful emptying of ventilator preventative effects.
5,46–51
circuits.
24,29,30
Although passive humidifiers or heat–moisture exchangers
decrease ventilator circuit colonisation, there are no consistent data In two prospective randomised trials, SDD was associated with higher
showing a reduction of the incidence of VAP and, therefore, they cannot ICU survival among patients receiving SDD,
52,53
although the benefits of
be recommended as a pneumonia prevention tool.
33–37
SDD in one study appeared to be restricted to patients with a mid-
60 EUROPEAN RESPIRATORY DISEASE
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