Ventilator-associated Pneumonia: The Potential Critical Role of Emergency Medicine in Prevention

Colonização e translocação bacteriana orofaríngea, gástrica e traqueal em crianças submetidas à ventilação pulmonar mecânica

“…Once reflux occurs, the upper airways are exposed to a high number of bacteria that may still migrate to the oropharynx by means of the external wall of the tubes. (7) In the present study, only two children were not submitted to gastric or postpyloric intubation.…”

“…The insertion of tubes into the nostril has been associated with greater risk for the development of sinusitis, which consequently increases the possibility of alteration in oropharyngeal colonization, since the bacteria present in the paranasal sinuses may migrate to this region. (7) Moreover, when gastric or post-pyloric tubes are used, occlusion of the esophageal sphincter is harmed, generating a potential risk for gastric reflux. Once reflux occurs, the upper airways are exposed to a high number of bacteria that may still migrate to the oropharynx by means of the external wall of the tubes.…”

Prevention of ventilator-associated pneumonia

“…21,24 Not all defense mechanisms are operational in critically ill patients due to underlying diseases, sedative medication, poor nutrition and medical devices, 22 such as the endotracheal tube (ETT) which is used in the MV and compromises the cough reflex and the mucociliary clearance (ETT increases mucous secretion and stagnation of secretions) and causes lesions on the surface of the tracheal epithelium. 21,25 The ETT cuff prevents the aspiration of large volume secretions; however, it is not completely airtight, since there is the possibility of establishing microchannels between the tracheal mucous and the cuff when it is distended, which increases the probability of microaspiration of the accumulated secretions above the cuff (subglottic secretions) to the lower airways. 25 In addition, pathogens that reach the ETT cuff are able to colonize the interior of the tube, ensuring access to the distal airways with the aid of the inspiratory flow from the MV, establishing posteriorly the lung infection.…”

“…21,25 The ETT cuff prevents the aspiration of large volume secretions; however, it is not completely airtight, since there is the possibility of establishing microchannels between the tracheal mucous and the cuff when it is distended, which increases the probability of microaspiration of the accumulated secretions above the cuff (subglottic secretions) to the lower airways. 25 In addition, pathogens that reach the ETT cuff are able to colonize the interior of the tube, ensuring access to the distal airways with the aid of the inspiratory flow from the MV, establishing posteriorly the lung infection. 24 Previous surgeries and medication, particularly antibiotherapy, may also predispose the patient to the disease.…”

“…It should be checked daily, at regular intervals, and maintained between 20 and 30 cm H 2 O: below this value the risk of pneumonia increases, and above it tracheal mucosal injuries can occur. 25,29 However, the British guidelines recommends a narrower range of pressure (>25 and <30 cm H 2 O) 28 and the American guidelines only recommend a minimum value of 20 cm H 2 O. 5,27 c) Aspiration of subglottic secretions Currently, aspiration of subglottic secretions is recommended by almost all guidelines, since studies show a reduction in the incidence of VAP when this preventive measure is used.…”