Ventilator-associated pneumonia: issues related to the artificial airway

Pooling of contaminated secretions above the cuff of the endotracheal tube predisposes patients to ventilator-associated pneumonia (VAP). Subglottic secretion drainage requires a special endotracheal tube that has a separate lumen that opens in the subglottic region above the tracheal tube. A recent meta-analysis of the 5 randomized clinical trials that evaluated the efficacy of removing these secretions found that this technique significantly reduces the incidence of VAP. One cost-effectiveness analysis showed savings of dollar 4,900 per episode of VAP prevented. Greatest benefit is derived by patients requiring fewer than 10 days of mechanical ventilation and not exposed to antibiotic therapy. Maintaining the intracuff pressure between 25 and 30 cm H2O is mandatory to guarantee effective drainage and safety. While silver-coated endotracheal tubes reduce pseudomonas pneumonia in intubated dogs and delay airway colonization in intubated patients, evaluation of studies with a variety of case mixes is warranted to identify subsets likely to benefit from the technique before it is implemented on a large scale. A patient who has a colonized airway and who undergoes percutaneous tracheotomy has an increased risk of VAP, particularly due to Pseudomonas aeruginosa, in the week following the procedure. As many studies suggest that incidence of VAP is highly dependent on the strategies of airway management, health care workers should be alerted to issues related to the artificial airway.