Preventing Ventilator-Associated Pneumonia - The Role of the Endotracheal Tube
Peter J. Young,
Alex J. Doyle.
The endotracheal tube, rather than the ventilator, is responsible for the vast majority of cases of ventilatorassociated
pneumonia (VAP). Tracheal intubation should be avoided, or early extubation performed, if at all possible.
With current high-volume low-pressure (HVLP) cuffs, pulmonary aspiration of microorganisms from the upper
aerodigestive tract normally occurs and is frequently silent, until there is a clinical respiratory deterioration. Aspiration
occurs by 3 mechanisms; channels within the HVLP cuff, in folding of the cuff upon movement and intermittent deflation
of the cuff. This aspiration is the pivotal step in the development of VAP. The diagnosis of VAP is notoriously inaccurate
and stifles the progress of research into prevention strategies. When treating bacteria present in the lung, the various
paradigms of VAP diagnosis remain the only (and best) tools that we have to decide when the benefits of antibiotics
outweigh the disadvantages. It is surprising, considering the accepted high mortality and cost of VAP, that until recently,
there has been a massive under investment from industry in preventative technologies. New technologies should address
the multiple factors implicated in the pathogenesis of VAP, including aspiration elimination by improved cuff designs.
However, surrogate outcomes, such as pulmonary aspiration and tracheal colonisation (a more rigorous standard to aspire
to), should be considered when evaluating preventative strategies. Pulmonary aspiration and/or tracheal colonisation by
pathogenic organisms are undesirable and should be unacceptable. This review appraises the role of the endotracheal tube
in both the development and prevention of VAP.
Keywords: Agento, CASS, cuff, endotracheal, high volume low pressure, HILO EVAC, HVLP, Lotrach, low volume low pressure,
LVLP, Microcuff, PneuX, sealguard, subglottic secretion drainage, taperguard, tube, ventilator-associated pneumonia
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