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Incidence of ventilator-associated pneumonia in patients undergoing elective tube exchange to LoTrach endotracheal tubes

Introduction

The objective was to study a cohort of general ICU patients electively reintubated with the LoTrach tracheal tube (tube exchange) to determine safety and to audit postprocedural ventilator-associated pneumonia (VAP). Emergency reintubation following elective or unplanned extubation is a known risk factor for subsequent VAP [1]; however, there are no published data on the effects of protocol-based elective tube exchange. The LoTrach tube prevents the pulmonary aspiration that occurs with conventional cuffs [2] and allows subglottic secretion management, thereby directly influencing two key steps in the pathogenesis of VAP.

Methods

Sequential patients (53 patients in 14 months) receiving the LoTrach tracheal tube and cuff pressure controller were studied. Patients either underwent an elective tube exchange (using a bougie, preprocedural preoxygenation, gastric tube aspiration, muscle relaxation and direct laryngoscopy to clear upper airway secretions) or were primary LoTrach intubations on the ICU. Three clinicians independently examined the critical care electronic patient record. VAP was identified by a fall in the PaO2/FaO2 ratio >25% or a clinical pulmonary infection score >5 and the presence of a positive qualitative tracheal aspirate. The international consensus criteria for VAP diagnosis were also used, as was the institution of antimicrobial therapy (if this was triggered by a clinical suspicion of VAP, then for the purposes of this study VAP was diagnosed).

Results

Forty-four (83%) patients underwent elective tube exchange. No complications were noted associated with the procedure. There were no episodes of VAP while the LoTrach was in situ. On an intention-to-treat basis there was a 1.8% VAP rate because one patient who required emergency reintubation following elective extubation received a conventional tube and developed VAP 2 days later. No other patients had antimicrobials begun for chest infections.

Conclusion

There were no complications associated with elective tube exchange and no subsequent cases of VAP in this cohort of patients who were reintubated with the LoTrach tube. Elective tracheal tube exchange can be safely performed in general ICU patients.

References

  1. 1.

    Torres A, et al.: Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 1995, 152: 137-134.

  2. 2.

    Young PJ, et al.: A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med 2006, 34: 632-639. 10.1097/01.CCM.0000201406.57821.5B

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Fletcher, A., Carter, J., Blunt, M. et al. Incidence of ventilator-associated pneumonia in patients undergoing elective tube exchange to LoTrach endotracheal tubes. Crit Care 13, P295 (2009). https://doi.org/10.1186/cc7459

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Keywords

  • Electronic Patient Record
  • Tube Exchange
  • Tracheal Aspirate
  • Clinical Pulmonary Infection Score
  • Unplanned Extubation