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Effects of tracheal orientation on development of ventilator-associated pneumonia: an experimental study

Alberto Zanella| Massimo Cressoni| Myra Epp| Viktoria Hoffmann| Mario Stylianou| Theodor Kolobow
Experimental
Volume 38, Issue 4 / April , 2012

Pages 677 - 685

Abstract

Purpose

Orientation of the trachea and tracheal tube below horizontal may prevent aspiration of oropharyngeal secretions into the lungs, which is a pivotal pathway in the pathogenesis of ventilator-associated pneumonia (VAP). The incidence of VAP was evaluated in swine with orientation of trachea and tracheal tube above horizontal (model of semirecumbent position, currently recommended in patients) and below horizontal.

Methods

Twenty-six mini-pigs were randomized into four groups: (A) eight mechanically ventilated with orientation of trachea 45° above horizontal for 72 h. In the remaining groups (B, C, D) the trachea was oriented 10° below horizontal, with (B) six mechanically ventilated for 72 h, (C) six mechanically ventilated for 72 h with enteral feeding, and (D) six mechanically ventilated for 168 h with enteral feeding. At the end of the study period, all pigs were sacrificed and the clinical diagnosis of VAP was microbiologically evaluated. No antibiotics were administered.

Results

All eight pigs kept orientated with the trachea 45° above horizontal developed VAP and respiratory failure (PaO2/FiO2 = 132 ± 139 mmHg) with a median of 5.5 pulmonary lobes out of 6 colonized with average colonization of 9.3 × 107 CFU/g. None of the 18 pigs kept oriented with the trachea below horizontal developed VAP; 16 had sterile lungs, while 2, ventilated for 7 days, developed a low level of colonization.

Conclusions

Orientation of the trachea above horizontal was uniformly associated with VAP and respiratory failure; positioning the trachea below horizontal consistently prevented development of VAP.

Keywords

References

  1. Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903
    • View reference on PubMed
  2. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M (1999) Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 354:1851–1858
    • View reference on PubMed
    • View reference on publisher's website
  3. Torres A, El-Ebiary M, Gonzalez J, Ferrer M, Puig de la Bellacasa J, Gene A, Martos A, Rodriguez-Roisin R (1993) Gastric and pharyngeal flora in nosocomial pneumonia acquired during mechanical ventilation. Am Rev Respir Dis 148:352–357
    • View reference on PubMed
  4. van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, Joore HC, van Schijndel RJ, van der Tweel I, Ramsay G, Bonten MJ (2006) Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 34:396–402
    • View reference on PubMed
    • View reference on publisher's website
  5. Panigada M, Berra L, Greco G, Stylianou M, Kolobow T (2003) Bacterial colonization of the respiratory tract following tracheal intubation-effect of gravity: an experimental study. Crit Care Med 31:729–737
    • View reference on PubMed
    • View reference on publisher's website
  6. Stiletto RJ (2003) Bacterial colonization of the respiratory tract under artificial ventilation: is there proof of clinically relevant effects of the endotracheal tube orientation under positioning therapy? Crit Care Med 31:973–974
    • View reference on PubMed
    • View reference on publisher's website
  7. Luna CM, Sibila O, Agusti C, Torres A (2009) Animal models of ventilator-associated pneumonia. Eur Respir J 33:182–188
    • View reference on PubMed
    • View reference on publisher's website
  8. Garrouste-Orgeas M, Chevret S, Arlet G, Marie O, Rouveau M, Popoff N, Schlemmer B (1997) Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. a prospective study based on genomic DNA analysis. Am J Respir Crit Care Med 156:1647–1655
    • View reference on PubMed
  9. Torres A, Serra-Batlles J, Ros E, Piera C, Puig de la Bellacasa J, Cobos A, Lomena F, Rodriguez-Roisin R (1992) Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 116:540–543
    • View reference on PubMed
  10. Zanella A, Cressoni M, Epp M, Stylianou M, Kolobow T (2008) A double-layer tracheal tube cuff designed to prevent leakage: a bench-top study. Intensive Care Med 34:1145–1149
  11. Torres A, El-Ebiary M, Soler N, Monton C, Fabregas N, Hernandez C (1996) Stomach as a source of colonization of the respiratory tract during mechanical ventilation: association with ventilator-associated pneumonia. Eur Respir J 9:1729–1735
    • View reference on PubMed
    • View reference on publisher's website
  12. Bassi GL, Zanella A, Cressoni M, Stylianou M, Kolobow T (2008) Following tracheal intubation, mucus flow is reversed in the semirecumbent position: possible role in the pathogenesis of ventilator-associated pneumonia. Crit Care Med 36:518–525
    • View reference on publisher's website
  13. Atkinson WJ (1970) Posture of the unconscious patient. Lancet 1:404–405
    • View reference on PubMed
    • View reference on publisher's website
  14. Alexiou VG, Ierodiakonou V, Dimopoulos G, Falagas ME (2009) Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. J Crit Care 24:515–522
    • View reference on PubMed
    • View reference on publisher's website
  15. Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, Jaeschke RZ, Brun-Buisson C (1998) Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 129:433–440
    • View reference on PubMed
  16. Orozco-Levi M, Torres A, Ferrer M, Piera C, El-Ebiary M, de la Bellacasa JP, Rodriguez-Roisin R (1995) Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med 152:1387–1390
    • View reference on PubMed
  17. Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M (1995) The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study EPIC International Advisory Committee. JAMA 274:639–644
    • View reference on PubMed
    • View reference on publisher's website
  18. Johanson WG Jr, Holcomb JR, Coalson JJ (1982) Experimental diffuse alveolar damage in baboons. Am Rev Respir Dis 126:142–151
    • View reference on PubMed
  19. Crouch TW, Higuchi JH, Coalson JJ, Johanson WG Jr (1984) Pathogenesis and prevention of nosocomial pneumonia in a nonhuman primate model of acute respiratory failure. Am Rev Respir Dis 130:502–504
    • View reference on PubMed
  20. Marquette CH, Wermert D, Wallet F, Copin MC, Tonnel AB (1999) Characterization of an animal model of ventilator-acquired pneumonia. Chest 115:200–209
    • View reference on PubMed
    • View reference on publisher's website
  21. Kuster SP, Ruef C, Ledergerber B, Hintermann A, Deplazes C, Neuber L, Weber R (2008) Quantitative antibiotic use in hospitals: comparison of measurements, literature review, and recommendations for a standard of reporting. Infection 36:549–559
    • View reference on PubMed
    • View reference on publisher's website
  22. Johanson WG Jr, Pierce AK, Sanford JP, Thomas GD (1972) Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med 77:701–706
    • View reference on PubMed
  23. Mauri T, Berra L, Kumwilaisak K, Pivi S, Ufberg JW, Kueppers F, Pesenti A, Bigatello LM (2010) Lateral-horizontal patient position and horizontal orientation of the endotracheal tube to prevent aspiration in adult surgical intensive care unit patients: a feasibility study. Respir Care 55:294–302
    • View reference on PubMed
  24. Aly H, Badawy M, El-Kholy A, Nabil R, Mohamed A (2008) Randomized, controlled trial on tracheal colonization of ventilated infants: can gravity prevent ventilator-associated pneumonia? Pediatrics 122:770–774
    • View reference on PubMed
    • View reference on publisher's website
  25. Hess DR (2005) Patient positioning and ventilator-associated pneumonia. Respir Care 50:892–898; discussion 898–899

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