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EDITORIALS: Christian Brun-Buisson Preventing ventilator associated pneumonia BMJ 2007; 334: 861-862 [Full text]

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Acid suppressants also contribute to ventilator associated pneumonia

David A Gorard   (29 April 2007)

Treating the symptom and not the cause

Duncan L Wyncoll, Dr Peter J Young, Consultant Intensivist, Queen Elizabeth Hospital, King's Lynn. PE30 4ET   (30 April 2007)

Primary prevention of Ventilator associated Pneumonia

R HARISH   (3 May 2007)

Acid suppressants also contribute to ventilator associated pneumonia 29 April 2007
David A Gorard, Consultant Gastroenterologist Wycombe Hospital, Bucks, HP11 2TT Send response to journal: Re: Acid suppressants also contribute to ventilator associated pneumonia	It is surprising that the possible deleterious effects of acid suppressive medication are not mentioned in Brun-Buisson’s summary of factors associated with ventilator associated pneumonia (1). H2-receptor antagonists and proton pump inhibitors are widely prescribed for stress ulcer prophylaxis in intensive care units. By increasing gastric pH, these drugs attenuate the stomach’s usual acid hostility to bacteria, theoretically allowing retrograde travel of bacteria into the oropahrynx. Although the evidence is sometimes contradictory, the ubiquitous administration of acid suppressing drugs to prevent stress ulcers in critically ill patients seems to be associated with an increased risk of ventilator associated pneumonia (2,3). Stress ulcer prophylaxis should be targeted towards specific patients (4) rather than be routinely prescribed in intensive care units. 1. Christian Brun-Buisson. Preventing ventilator associated pneumonia. BMJ 2007; 334: 861-862. 2. Messori A, Trippoli S, Vaiani M, Gorini M, Corrado A. Bleeding and pneumonia in intensive care patients given ranitidine and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled trials. BMJ 2000; 321: 1103-6. 3. Collard HR, Saint S, Matthay MA. Prevention of ventilator- associated pneumonia: an evidence-based systematic review. Ann Intern Med 2003; 138: 494-501. 4. Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med 1994; 330: 377–381. Competing interests: None declared
Treating the symptom and not the cause 30 April 2007
Duncan L Wyncoll, Consultant Intensivist St Thomas' Hospital, London SE1 7EH, Dr Peter J Young, Consultant Intensivist, Queen Elizabeth Hospital, King's Lynn. PE30 4ET Send response to journal: Re: Treating the symptom and not the cause	Oral antiseptics should probably be part of a multifacted preventive package of ventilator associated pneumonia (VAP) as suggested by Dr Brun- Buisson (1). However, it is just another intervention in the ventilated patient, like semirecumbent positioning and care of the ventilator circuit, that merely addresses the symptom and does not focus on the real cause of VAP. It is now widely recognised that the pivotal step in the pathogenesis of the majority of VAP is aspiration of secretions past the cuff of the tracheal tube causing lower airway contamination, leading in susceptible patients to tissue invasion and pneumonia (2). Aspiration past tracheal tubes occurs because of a design defect in almost all cuffs currently available, with leakage along folds within the cuff wall. The presence of pepsin in tracheobronchial secretions (a marker of gastric regurgitation and aspiration) was shown by Methany et al (3) to be present in 89% of patients at some stage during their critical care stay. Moreover, this was the most significant independent risk factor for the developement of VAP. 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, but currently relatively ignored, problem of pulmonary aspiration by cuff improvements (4), may have a substantial impact on VAP and reduce the requirement for topical antiseptics or antibiotics (5). References 1. Brun-Buisson C. Preventing ventilator associated pneumonia. BMJ 2007;334:861-862 2. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med 2004;32:1396-1405. 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;34:1007-1015. 4. Young PJ, Pakeerathan S, Blunt MC, Subramanya S. A low-volume, low -pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med 2006;34:632-639. 5. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for the prevention of pneumonia in mechanically ventilated aduls:systematice review and meta-analysis. BMJ 2007;334:889-893. Competing interests: Dr Wyncoll has received one speaker fee from Venner Capital, the manufacturer of the LoTrach tracheal tube. Dr Peter Young consults and has received educational and research support from Venner Capital.
Primary prevention of Ventilator associated Pneumonia 3 May 2007
R HARISH, Consultant Anaesthetist and burns intensivist Morriston Hospital, Swansea Send response to journal: Re: Primary prevention of Ventilator associated Pneumonia	I read with interest the editorial by Professor Brun-Bruisson on ventilator associated pneumonia(VAP) and completely endorse with the need of a multifaceted preventive approach in the at risk group of patients for developing VAP. However, I feel that the one of the important preventive factor mentioned ie. the prevention of cross transmission, seems to have received little mentioning in the article. Despite many preventive strategies been suggested and studied, basic hand hygiene and careful infection control practices remains the most effective method in controlling nosocomial infections in intensive care patients. There is enough evidence from observational and cross sectional studies that physicians and health care staff have shown poor compliance (40-50%) and adherence to basic hand washing or use of alcohol based handrub 1,2. The results of the meta-analysis needs to be substantiated by large randomised controlled trials, with consideration to the possible risk of resistant micro-organisms arising from the use of topical antiseptics while we reinstate and reinforce the ideology of hand hygiene. References: 1. Pittet D, Simon A, Hugonnet S. Hand Hygiene among Physicians: performance, beliefs, and perceptions. Annals of Internal Medicine 2004; 141:1-4 2. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Annals of Internal Medicine 1999; 130: 126-130 Competing interests: None declared