Resp Care
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Albuterol delivery through a tracheostomy tube is affected by device (nebulizer vs metered-dose inhaler), interface (mask vs T-piece), bias flow, and humidification. ⋯ Albuterol delivery via tracheostomy was affected by the delivery device (nebulizer vs inhaler), bias gas flow, and the patient interface.
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Pooling of contaminated secretions above the cuff of the endotracheal tube predisposes patients to ventilator-associated pneumonia (VAP). Subglottic secretion drainage requires a special endotracheal tube that has a separate lumen that opens in the subglottic region above the tracheal tube. A recent meta-analysis of the 5 randomized clinical trials that evaluated the efficacy of removing these secretions found that this technique significantly reduces the incidence of VAP. ⋯ While silver-coated endotracheal tubes reduce pseudomonas pneumonia in intubated dogs and delay airway colonization in intubated patients, evaluation of studies with a variety of case mixes is warranted to identify subsets likely to benefit from the technique before it is implemented on a large scale. A patient who has a colonized airway and who undergoes percutaneous tracheotomy has an increased risk of VAP, particularly due to Pseudomonas aeruginosa, in the week following the procedure. As many studies suggest that incidence of VAP is highly dependent on the strategies of airway management, health care workers should be alerted to issues related to the artificial airway.
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Review Comparative Study
Noninvasive positive-pressure ventilation and ventilator-associated pneumonia.
There is much interest in the use of noninvasive positive-pressure ventilation (NPPV) to prevent intubation and afford a survival benefit for patients. The risk of pneumonia in patients receiving NPPV has been reported in 12 studies. Compared to patients receiving invasive mechanical ventilation (4 studies), the pneumonia rate is lower with the use of NPPV (relative risk [RR] 0.15, 95% confidence interval [CI] 0.04 to 0.58, p = 0.006). ⋯ One randomized controlled trial of continuous positive airway pressure compared with standard treatment in patients who developed acute hypoxemia after elective major abdominal surgery reported a lower rate of pneumonia with continuous positive airway pressure (2% vs 10%, RR 0.19, 95% CI 0.04 to 0.88, p = 0.02). In patients who are appropriate candidates for NPPV or continuous positive airway pressure, the available evidence suggests a benefit in terms of a lower risk of pneumonia. Perhaps "endotracheal-tube-associated pneumonia" is a better term than "ventilator-associated pneumonia."
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The gastrointestinal tract is believed to play an important role in ventilator-associated pneumonia (VAP), because during critical illness the stomach often is colonized with enteric Gram-negative bacteria. These are the same bacteria that frequently are isolated from the sputum of patients with VAP. Interventions such as selective decontamination of the digestive tract (SDD), use of sucralfate for stress ulcer prophylaxis, and enteral feeding strategies that preserve gastric pH, or lessen the likelihood of pulmonary aspiration, are used to decrease the incidence of VAP. ⋯ Rather, therapy should be focused on strategies other than antibiotic prophylaxis. Second, in patients who are at risk for clinically important gastrointestinal bleeding, a histamine-2 receptor antagonist should be used for stress ulcer prophylaxis, rather than sucralfate, because histamine-2 receptor antagonist provides substantially better protection without substantially increasing the risk of VAP. Third, post-pyloric enteral feeding may reduce the incidence of VAP.