Pulmonary Aspiration of Gastric Contents in Patients Receiving Mechanical Ventilation: The Effect of Body Position

Torres, Antoni; Serra-Batllés, Joan; Ros, Emilio; Piera, Carles; Bellacasa, Jorge Puig de la; Cobos, Albert; Lomeña, Francisco; Rodríguez-Roisín, Robert

doi:10.7326/0003-4819-116-7-540

Cited by 641 publications

(293 citation statements)

References 22 publications

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“…Radionuclide studies reveal increased tracheal penetration of gastric contents when intubated patients are supine (85,159,201). Drakulovic et al found that the simple elevation of the head of bed to 45°results in dramatic reductions in VAP incidence and a trend toward reduced mortality (54).…”

Section: Preventionmentioning

confidence: 99%

Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention

2006

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SUMMARY While critically ill patients experience a life-threatening illness, they commonly contract ventilator-associated pneumonia. This nosocomial infection increases morbidity and likely mortality as well as the cost of health care. This article reviews the literature with regard to diagnosis, treatment, and prevention. It provides conclusions that can be implemented in practice as well as an algorithm for the bedside clinician and also focuses on the controversies with regard to diagnostic tools and approaches, treatment plans, and prevention strategies.

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Section: Preventionmentioning

confidence: 99%

Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention

2006

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“…Aspiration of gastric contents is a recognized risk factor for ventilator-associated pneumonia in critically ill patients (9)(10)(11)(12). However, more information is needed to determine the extent to which the frequency of tracheobronchial aspiration of gastric contents predisposes to pneumonia and other adverse outcomes.…”

mentioning

confidence: 99%

Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: Frequency, outcomes, and risk factors

Metheny

Clouse

Chang

et al. 2006

Critical Care Medicine

321

235

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Objectives-To describe the frequency of pepsin-positive tracheal secretions (a proxy for the aspiration of gastric contents), outcomes associated with aspiration (including a positive Clinical Pulmonary Infection Score [a proxy for pneumonia] and use of hospital resources), and risk factors associated with aspiration and pneumonia in a population of critically ill tube-fed patients.Design-Prospective descriptive study conducted over a 2-yr period. Setting-Five intensive care units in a university-affiliated medical center with level I trauma status.Patients-Each of the 360 adult patients participated for 4 days. Among the inclusion criteria were mechanical ventilation and tube feedings. An exclusion criterion was physician-diagnosed pneumonia at the time of enrollment. Intervention-None.Measurements and Major Results-Almost 6,000 tracheal secretions collected during routine suctioning were assayed for pepsin; of these, 31.3% were positive. At least one aspiration event was identified in 88.9% (n = 320) of the participants. The incidence of pneumonia (as determined by the Clinical Pulmonary Infection Score) increased from 24% on day 1 to 48% on day 4. Patients with pneumonia on day 4 had a significantly higher percentage of pepsin-positive tracheal secretions than did those without pneumonia (42.2% vs. 21.1%, respectively; p < .001). Length of stay in the intensive care unit and need for ventilator support were significantly greater for patients with pneumonia (p < .01). A low backrest elevation was a risk factor for aspiration (p = .024) and pneumonia (p = .018). Other risk factors for aspiration included vomiting (p = .007), gastric feedings (p = .009), a Glasgow Coma Scale score <9 (p = .021), and gastroesophageal reflux disease (p = .033). The most significant independent risk factors for pneumonia were aspiration (p < .001), use of paralytic agents (p = .002), and a high sedation level (p = .039).Conclusions-Aspiration of gastric contents is common in critically ill tube-fed patients and is a major risk factor for pneumonia. Furthermore, it leads to greater use of hospital resources. Modifiable risk factors for aspiration need to be addressed. Keywords critical illness; enteral nutrition; aspiration pneumonia; risk factors; gastroesophageal reflux; gastric emptyingThe authors have no financial interests to disclose.The study was performed at Saint Louis University Hospital, in St. Louis, MO. NIH Public Access Author ManuscriptCrit Care Med. Author manuscript; available in PMC 2008 May 23. Published in final edited form as:Crit Care Med. 2006 April ; 34(4): 1007-1015. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptTracheobronchial aspiration can be defined as the inhalation of oropharyngeal or gastric contents into the respiratory tract (1). Although aspiration from either source is important, the type of greatest concern in critically ill tube-fed patients is tracheobronchial aspiration of gastric contents. The extent to which aspiration of gastric contents occurs is difficu...

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“…Furthermore, the isolation of the same organisms from the stomach, pharynx and endobronchial samples occurred in 32% of semirecombent patients compared with 68% of supine patients [80]. Gastro-oesophageal reflux, however, occurs irrespective of body position in mechanically ventilated patients with nasogastric tubes [81].…”

Section: Gastro-oesophageal Refluxmentioning

confidence: 99%

Ventilator‐associated pneumoniaDiagnosis, pathogenesis and prevention

Young¹,

Ridley²

1999

Anaesthesia

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SummaryVentilator-associated pneumonia is common, difficult to diagnose, affects the most vulnerable of patients and carries a high mortality. During prolonged mechanical ventilation the oropharynx, sinuses, dentition and stomach of critically ill patients become colonised with pathogenic bacteria. Colonised secretions pool in the oropharynx and subglottic space. These secretions repeatedly gain access to the lower airways by leakage past the tracheal tube cuff. If host defence mechanisms are overwhelmed, multiplication occurs in the lower respiratory tract producing an inflammatory response in the bronchioles and alveoli. The inflammatory response is characterised by capillary congestion, leucocyte and macrophage infiltration and fibrinous exudation into the alveolar spaces. If this inflammatory response occurs more than 48 h after intubation, it is called ventilatorassociated pneumonia. Prevention depends on reducing upper airway and gastrointestinal reservoirs of bacteria, reducing or abolishing aspiration of these bacteria past the tracheal tube cuff and enhancing bacterial clearance from the lower airways. Despite an increased understanding of the pathogenesis and diagnosis of ventilator-associated pneumonia (VAP), prevention has remained problematic. There is now good evidence for continuous leakage of infected secretions past the tracheal tube cuff being responsible for VAP. As a result, VAP strikes critically ill patients and increases their morbidity and mortality. The aim of this review is to discuss the diagnosis and pathogenesis of VAP, including a brief review of natural defence mechanisms. The review also covers the prevention of VAP with special reference to new developments aimed at reducing aspiration past the cuff. Definition

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Pulmonary Aspiration of Gastric Contents in Patients Receiving Mechanical Ventilation: The Effect of Body Position

Abstract: We conclude that the supine position and length of time the patient is kept in this position are potential risk factors for aspiration of gastric contents. Elevating the head of the bed for patients who can tolerate the semirecumbent position may be a simple, no-cost prophylactic measure.

Cited by 641 publications

References 22 publications

Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention

Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention

Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: Frequency, outcomes, and risk factors

Ventilator‐associated pneumoniaDiagnosis, pathogenesis and prevention

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