Search

Seminal studies have demonstrated that tracheally intubated, mechanically ventilated patients, positioned in supine horizontal position, are at a high risk of developing ventilator-associated pneumonia, through aspiration of gastric pathogens. In the 1990s, innovative clinical findings promoted a radical change in practice, through the use of the semirecumbent position in all mechanically ventilated patients. Here, we critically review the main indications, pulmonary effects, and controversies on the use of the semirecumbent position. Also, we will depict potential roles of prone and lateral positions in the prevention of ventilator-associated pneumonia. Our review will span from preclinical experimental insights to clinical evidence, and we will discuss potential controversies on the use of the semirecumbent position as the standard of care. We will also detail potential alternatives to ultimately improve outcomes of tracheally intubated and mechanically ventilated patients. [ABSTRACT FROM AUTHOR]

The authors discuss several studies related to clinical practice in intensive care units. Topics covered include the impact of routine changes of respiratory care devices on risk of ventilator-associated pneumonia, the cost-effectiveness of not routinely changing in-line suction catheters in less than 500 subjects who required mechanical ventilation, and heterogeneity in the frequency of cuff pressure assessments in Australia.

Antibiotic-resistant bacterial biofilm may quickly form on endotracheal tubes (ETTs) and can enter the lungs, potentially causing pneumonia. In an attempt to prevent bacterial colonization, we developed and tested in an in-vitro study and animal study several antibacterial-coated ETTs (silver sulfadiazine with and without carbon in polyurethane, silver sulfadiazine and chlorhexidine with and without carbon in polyurethane, silver–platinum with and without carbon in polyurethane, chlorhexidine in polyurethane, and rose bengal for UV light). After preliminary studies, silver sulfadiazine in polyurethane (SSD-ETT) was selected among the coatings to be challenged every 24 h with 104–106 Pseudomonas aeruginosa/ml and evaluated at 6 h, 24 h, and 72 h with standard microbiological studies, scanning electron microscopy, and confocal scanning microscopy. Subsequently, eight sheep were randomized to receive either a SSD-ETT or a standard ETT (St-ETT). After 24 h of mechanical ventilation, standard microbiological studies were performed together with scanning electron microscopy and confocal microscopy. In the in-vitro study SSD-ETT remained bacteria-free for up to 72 h, whereas St-ETT showed heavy P. aeruginosa growth and biofilm formation ( p < 0.01). In sheep, the SSD-ETT group showed no bacterial growth in the ETT, ventilator tubing, and lower respiratory tract, while heavy colonization was found in the St-ETT ( p < 0.01), ventilator tubing ( p = 0.03), and lower respiratory tract ( p < 0.01). This study describes several effective and durable antibacterial coatings for ETTs. Particularly, SSD-ETT showed prevention against P. aeruginosa biofilm formation in a 72-h in-vitro study and lower respiratory tract colonization in sheep mechanically ventilated for 24 h. [ABSTRACT FROM AUTHOR]

Objective: To assess the long-term benefit from antibacterial coatings of the tracheal tube (ETT), and to keep clean the lumen of the ETT.Design: Experimental animal study.Setting: USA National Institutes of Health.Subjects: Twelve sheep.Interventions: Twelve ETTs were internally dip-coated with a silver-sulfadiazine in polyurethane. We developed a concentric inflatable silicone rubber "razor", the Mucus Shaver (MS), to shave the ETT lumen free of mucus. In a single pass, we cleaned all mucus from the internal surface of the ETT.Control Group: Five intubated sheep were mechanically ventilated for 72 h. The ETT was suctioned every 6 h.Study Group: Six sheep were intubated and mechanically ventilated for 72 h. The ETT was suctioned and cleaned with the MS every 6 h. An additional sheep was intubated and mechanically ventilated for 168 h. Bacteriologic studies and scanning electron microscopy were performed to assess bacterial colonization and thickness of secretions on the internal surface of the ETT.Measurements and Main Results: In the control group, the ETT was always heavily colonized: median debris thickness was 380 microm, range 270-550 microm. In the study group, there was no colonization and no secretions in the ETT, except for three ETT that were colonized solely at the very tip.Conclusions: Silver-based coating of ETT cleaned with the MS every 6 h significantly reduces accumulation of mucus/secretion and bacterial growth within the ETT following 72 h of mechanical ventilation. [ABSTRACT FROM AUTHOR]

The authors discuss on the oropharyngeal decontamination for the prevention of ventilator-associated pneumonia (VAP). The authors say that oropharyngeal colonization plays a pivotal role in the pathogenesis of VAP and the analysis of the oropharyngeal microbiota of human using real-time PCR demonstrated bacterial diversity. They state that the oropharyngeal colonization with respiratory pathogens is prevented by physical-chemical properties of oral mucosa surface, immunoglobulins and proteases.

The authors comment on a study by Sinuff et al published in this issue about the implementation of guidelines directed toward the entire intensive care unit (ICU) workforce to prevent, diagnose and treat ventilator-associated pneumonia (VAP). They noted that the intervention was modifiable throughout the study which allowed clinicians to increase their educational exposure. They cited that the costs of implementing new guidelines through a multifaceted intervention in the ICU are unknown.

• Few effective strategies against endotracheal tube biofilms are currently available. • Telavancin reduced methicillin-resistant S. aureus load in endotracheal tubes. • This treatment also reduced biofilm thickness in the endotracheal tubes. The effect of systemic treatment of ventilator-associated pneumonia (VAP) with telavancin, a semisynthetic lipoglycopeptide with good penetration in vitro biofilms, has not been tested in vivo during mechanical ventilation. This study examined the efficacy of telavancin compared with linezolid against endotracheal tube (ETT) biofilms in a porcine model of methicillin-resistant Staphylococcus aureus (MRSA) VAP. VAP was induced in 18 pigs by instilling 107 colony-forming units (CFU/mL) of an MRSA strain susceptible to telavancin and linezolid into each pulmonary lobe. Randomization into three groups was done at pneumonia diagnosis: control (IV glucose 0.5% solution q24); linezolid (10 mg/kg q12) and telavancin groups (22.5 mg/kg q24). After 72 h of MV, data regarding bronchoalveolar lavage (BAL), tracheal aspirate (TA), ETT MRSA biofilm load and thickness measured by scanning electron microscopy were obtained. All 18 pigs completed the study. MRSA was isolated in 100% of ETTs from the control and linezolid groups and in 67% from the telavancin group. Telavancin treatment presented a lower MRSA load compared to the control and linezolid treatments (telavancin median [interquartile range (IQR)] = 1.94 [0.00–5.45], linezolid 3.99 [3.22–4.68] and control 4.93 [4.41–5.15], P = 0.236). Telavancin treatment also resulted in the lowest biofilm thickness according to the SEM (4.04 [2.09–6.00], P < 0.001). We found a positive correlation between ETT and BAL load (rho = 0.511, P = 0.045). In our VAP model, systemic telavancin treatment reduced ETT MRSA occurrence, load, and biofilm thickness. Our findings may have a bearing on ICU patients' clinical outcomes. [ABSTRACT FROM AUTHOR]

The article investigates the effects of systemic corticosteroids in patients with intensive care unit (ICU)-acquired pneumonia. Results suggest that systemic corticosteroids should be used very cautiously in critically-ill patients because this treatment is strongly tied up with increased risk of death in patients with ICU-acquired pneumonia. Decreased inflammatory response may reportedly lead to delayed clinical suspicion of ICU-acquired pneumonia and high bacterial count.

The article presents a study that compares the efficacy of linezolid and vancomycin in an experimental model of pneumonia induced by methicillin-resistant Staphylococcus aureus in ventilated pigs. Compared with vancomycin treatments, linezolid treatment showed better results of pharmacokinetics and pharmacodynamics profile in serum and lung tissue. The researchers concluded that linezolid exhibited a better efficacy than vancomycin due to a better pharmacokinetics and pharmacodynamics index.