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
1. Brun-Buisson C. Preventing ventilator associated pneumonia. BMJ
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
4. Young PJ, Pakeerathan S, Blunt MC, Subramanya S. A low-volume, low
-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med
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.
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.
Competing interests: No competing interests