Mechanisms of gastroesophageal reflux in critically ill mechanically ventilated patients

Nind, Garry; Chen, Wei-Hao; Protheroe, Richard; Iwakiri, Katsuhiko; Fraser, Robert; Young, Robert J.; Chapman, Marianne J.; Nguyen, Nam Q.; Sifrim, Daniel; Rigda, Rachael S.; Holloway, Richard H.

doi:10.1053/j.gastro.2004.12.034

Cited by 67 publications

(51 citation statements)

References 37 publications

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“…16 We detected amylase in the oral secretions of all patients and in the tracheal secretions of 5 (38%). The number of patients positive for amylase during the second specimen collection decreased to 4, and the mean value was lower.…”

Section: Discussionmentioning

confidence: 81%

Pepsin and Amylase in Oral and Tracheal Secretions: A Pilot Study

Sole¹,

Conrad²,

Bennett³

et al. 2014

American Journal of Critical Care

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worth, RN, MSN, CCRN, CCNS, and Devendra Indulal Mehta, MBBS, MSc(dist), MRCP Background Endotracheal intubation increases the risk for microaspiration of secretions around the tube cuff. Pepsin has been used as a biomarker for gastric aspiration. Amylase is a newer proposed biomarker for aspiration of oral contents. Objective To assess the presence of pepsin and amylase in paired oral-tracheal secretions of adult patients treated with mechanical ventilation. Methods In this descriptive study, paired samples of oral and tracheal secretions were obtained from adult patients at baseline and again within 4 hours when a need for endotracheal suctioning was assessed. Assays of pepsin and amylase were processed in a specialty diagnostic laboratory. Results The sample consisted of 10 men and 3 women with a median age of 56 years. The majority were intubated with a subglottic suction endotracheal tube (9 patients, 69%), receiving synchronized intermittent mandatory ventilation (10 patients; 77%), and receiving enteral feedings (11 patients; 85%) through a tube distally placed in the stomach (8 patients; 67%). Pepsin was present in oral secretions of 9 patients (69%), and in tracheal specimens of 7 patients (54%) at one or both sampling times. Amylase was detected in all patients' oral secretions and in tracheal secretions of 5 patients (38%) at one or both sampling times. Conclusions Many patients had pepsin, amylase, or both in tracheal aspirates. Pepsin was more commonly detected than was amylase. Although the relationship of this finding to longterm outcomes was not assessed, findings indicate that microaspiration of oral and gastric secretions occurs frequently.

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Section: Discussionmentioning

confidence: 81%

Pepsin and Amylase in Oral and Tracheal Secretions: A Pilot Study

Sole¹,

Conrad²,

Bennett³

et al. 2014

American Journal of Critical Care

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“…The mechanisms that cause GER in mechanically ventilated patients differ from conscious patients [1] . Transient lower esophageal sphincter relaxation (TLESR) is believed to be the major mechanism of acid reflux in awake patients, with a defective basal LES pressure caused by hiatus hernia and straining associated with increased abdominal pressure being contributing factors [18,19] .…”

Section: Discussionmentioning

confidence: 99%

“…Transient lower esophageal sphincter relaxation (TLESR) is believed to be the major mechanism of acid reflux in awake patients, with a defective basal LES pressure caused by hiatus hernia and straining associated with increased abdominal pressure being contributing factors [18,19] . In contrast, the absent or very low basal LES pressure induced by mechanical ventilation, opiates, endotoxemia-related sepsis and nasogastric tube are the major causes of reflux in critically ill patients [1,2,7,20] . The latter is considered to be a key factor for both the development and the degree of GER [21] .…”

Section: Discussionmentioning

confidence: 99%

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Reasons of PEG failure to eliminate gastroesophageal reﬂuxin mechanically ventilated patients

Douzinas¹,

Andrianakis²,

Livaditi³

et al. 2009

WJG

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AIM:To investigate factors predicting failure of percutaneous endoscopic gastrostomy (PEG) to eliminate gastroesophageal reflux (GER). METHODS:Twenty-nine consecutive mechanically ventilated patients were investigated. Patients were evaluated for GER by pH-metry pre-PEG and on the 7th post-PEG day. Endoscopic and histologic evidence of reflux esophagitis was also carried out. A beneficial response to PEG was considered when pH-metry on the 7th post-PEG day showed that GER was below 4%. RESULTS:Seventeen patients responded (RESP group) and 12 did not respond (N-RESP) to PEG. The mean age, sex, weight and APACHE Ⅱ score were similar in both groups. GER (%) values were similar in both groups at baseline, but were significantly reduced in the RESP group compared with the N-RESP group on the 7th post-PEG day [2.5 (0.6-3.8) vs 8.1 (7.4-9.2, P < 0.001)]. Reflux esophagitis and the gastroesophageal flap valve (GEFV) grading differed significantly between the two groups (P = 0.031 and P = 0.020, respectively). Histology revealed no significant differences between the two groups. CONCLUSION:Endoscopic grading of GEFV and the presence of severe reflux esophagitis are predisposing factors for failure of PEG to reduce GER in mechanically ventilated patients.

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“…There is growing evidence that oropharyngeal dysphagia plays a critical role in aspiration pneumonia and VAP in mechanically ventilated patients [3,4]. Brain injury, severe stroke and unconsciousness, due to sedatives and hypnotics, disturb the swallowing reflex.…”

Section: To the Editorsmentioning

confidence: 99%

Nasogastric tube feeding is a cause of aspiration pneumonia in ventilated patients

Teramoto¹

2006

Eur Respir J

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complaints were diagnosed with bronchitis. This resulted in a more frequent use of inhaled steroids and bronchodilators in Dutch children as compared with German children [2].We cannot exclude the fact that a possible geographically heterogeneous worldwide Chlamydia pneumoniae pandemic could contribute to changes in asthma prevalences in different countries. However, it seems unlikely to us that this would be the sole explanation, as not all asthmatics (established or newly diagnosed) have C. pneumoniae present in bronchoalveolar lavage fluid. Moreover, the widespread use of (macrolide) antibiotics has not prevented a clear increase in asthma prevalence. On the contrary, it seems that a decrease in hospitalisation and mortality is strongly associated with an increase in the use of inhaled steroids [3], and there is no indication that this is associated with the use of antibiotics.However, it is certainly worthwhile to pay attention to the socalled Chlamydia-asthma theory proposed by D.L. Hahn and to investigate the presence of Chlamydia pneumoniae or other infectious organisms in new asthma patients.

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Mechanisms of gastroesophageal reflux in critically ill mechanically ventilated patients

Cited by 67 publications

References 37 publications

Pepsin and Amylase in Oral and Tracheal Secretions: A Pilot Study

Pepsin and Amylase in Oral and Tracheal Secretions: A Pilot Study

Reasons of PEG failure to eliminate gastroesophageal reﬂuxin mechanically ventilated patients

Nasogastric tube feeding is a cause of aspiration pneumonia in ventilated patients

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