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Above and beyond: biofilm and the ongoing search for strategies to reduce ventilator-associated pneumonia (VAP)
Critical Care volume 24, Article number: 510 (2020)
We read with great interest the article by Thorarinsdottir et al.  that compared biofilm formation on three endotracheal tube (ETT) types with the finding that biofilm formation was reduced in silicone and noble-metal coated ETTs compared to uncoated ETTs. Their findings have significant implications during the current pandemic given the prolonged intubation times of COVID-19 patients and many develop superimposed pneumonias during their hospital course. It is intriguing that simply changing the ETT’s coating may have significant implications in this patient population with already limited pulmonary reserve that is unable to tolerate additional insults to their lung from a ventilator-associated pneumonia (VAP). However, given the prolonged intubation times of COVID-19 patients, it is likely that the ETT biofilm burden will be substantial no matter which surface coating is utilized. Here, we discuss other strategies to reduce the incidence of VAP.
It is widely accepted that two mechanisms lead to VAP: aspiration of oral-gastric contents and microbial biofilm development on the ETT. Prevention is further complicated by a reduction in host mechanisms such as coughing and mucociliary clearance. Biofilms specifically cause two primary issues: (1) non-microbiological problem of intraluminal narrowing and (2) microbiological problem of biofilm development on the inner/outer surfaces of the ETT. The latter issue relates to our current discussion here.
Table 1 summarizes the mechanism, preventive measures, and methods that have been investigated to prevent aspiration and minimize biofilm burden related to tracheal seeding, microaspiration, biofilm formation, ciliary dysfunction, and the cough reflex. Despite substantial research that has continued, available tools to prevent VAP have changed very little. Many of the recommendations from the most recent 2014 Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA)  consensus recommendations aimed at preventing VAP are controversial and have been questioned, including the efficacy and safety of oral chlorhexidine and head of bed elevation [3, 4].
While it is important to develop technologies that minimize ETT microbial burden, other more practical, easily accessible, and affordable preventative measures should continue to be practiced and investigated. As previously advised by Klompas et al. , continuing with simple and proven methods that decrease aspiration load and biofilm formation should be maximized. While avoiding intubation may be the surest way to prevent VAP, this is not always possible. Incorporating the latest evidence into our current practice bundles may be key to improving clinical outcomes of COVID-19 patients.
Availability of data and materials
Thorarinsdottir HR, Kander T, Holmberg A, Petronis S, Klarin B. Biofilm formation on three different endotracheal tubes: a prospective clinical trial. Crit Care. 2020;24(1):382.
Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(Suppl 2):S133–54.
Wang L, Li X, Yang Z, Tang X, Yuan Q, Deng L, Sun X. Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults requiring mechanical ventilation. Cochrane Database Syst Rev 2016, Issue 1. Art. No.: CD009946.
Klompas M, Li L, Kleinman K, et al. Associations between ventilator bundle components and outcomes. JAMA Intern Med. 2016;176:1277–83.
Klompas M, Berra L, Branson R. Beware the siren’s song of novel endotracheal tube designs. Intensive Care Med. 2017;43(11):1708–11.
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TS, EAB, and MGC declare to have no competing interests. LB receives salary support from K23 HL128882/NHLBI NIH as principal investigator for his work on hemolysis and nitric oxide. LB receives technologies and devices from iNO Therapeutics LLC, Praxair Inc., Masimo Corp. LB receives a grant from iNO Therapeutics LLC and research funds from the Reginald Jenney Endowment Chair at Harvard Medical School.
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Sakano, T., Bittner, E.A., Chang, M.G. et al. Above and beyond: biofilm and the ongoing search for strategies to reduce ventilator-associated pneumonia (VAP). Crit Care 24, 510 (2020). https://doi.org/10.1186/s13054-020-03234-5
- Ventilator-associated pneumonia
- Endotracheal tube design
- Coated endotracheal tubes