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BMJ. 2007 May 12; 334(7601): 967–968.
PMCID: PMC1867889
Pneumonia from Ventilation

Oral decontamination treats the symptom, not the cause

Duncan L Wyncoll, consultant intensivist1 and Peter J Young, consultant intensivist2

Oral antiseptics, like semirecumbent positioning and care of the ventilator circuit, merely address the symptom and not the cause of ventilator associated pneumonia (VAP).1

The pivotal step in the pathogenesis of most cases is aspiration of secretions past the cuff of the tracheal tube.2 Aspiration occurs because of a design defect in almost all cuffs currently available, with leakage along folds in the cuff wall. Pepsin (a marker of gastric regurgitation and aspiration) is present in tracheobronchial secretions in 89% of patients at some stage during their stay in critical care and is the most important independent risk factor for developing VAP.3

Manufacturers are now beginning to improve the design of tracheal tubes, ensuring maximal cuff performance and incorporating subglottic secretion drainage ports and antibacterial/non-stick linings. Simply preventing the ubiquitous problem of pulmonary aspiration by cuff improvements may have a substantial impact on VAP and reduce the requirement for topical antiseptics or antibiotics.4 5

Notes

Competing interests: DLW has received one speaker fee from Venner Capital, the manufacturer of the LoTrach tracheal tube. PJY consults and has received educational and research support from Venner Capital.

References

1. Brun-Buisson C. Preventing ventilator associated pneumonia. BMJ 2007;334:861-2. (28 April.) [PMC free article] [PubMed]
2. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med 2004;32:1396-405. [PubMed]
3. Metheny NA, Clouse RE, Chang YH, Stewart BJ, Oliver DA, Kollef MH. Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors. Crit Care Med 2006;34:1007-15. [PMC free article] [PubMed]
4. Young PJ, Pakeerathan S, Blunt MC, Subramanya S. A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med 2006;34:632-9. [PubMed]
5. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for the prevention of pneumonia in mechanically ventilated adults: systematice review and meta-analysis. BMJ 2007;334:889-93. (28 April.) [PMC free article] [PubMed]

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