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Tracheotomy and ventilator-associated pneumonia: the importance of oral care

Critical Care Directorate, University Hospital of Wales, Cardiff, UK.

To the Editors:

We read with interest the recent study of Nseir et al. 1, which demonstrated that tracheotomy was independently associated with a decreased risk of ventilator-associated pneumonia (VAP). The authors offered several potential explanations as to why tracheotomised patients should be at decreased risk of VAP compared to patients with translaryngeal intubation. These included liberation of the vocal cords, resulting in a reduced risk of aspiration of contaminated oropharyngeal secretions into the lung and the reduction in bacterial biofilm formation associated with regular changing of the tracheotomy cannula, and facilitation of weaning, leading to a shorter duration of mechanical ventilation.

An additional explanation that should also be considered is differences in the quality of oral care between tracheotomised patients and those with translaryngeal intubation. There is increasing evidence that dental plaque serves as an important reservoir for respiratory pathogens implicated in VAP 2. Indeed, some hospitals have instigated formal oral care programmes in order to reduce VAP rates in high-risk patients 3. However, in patients intubated via the translaryngeal route, the endotracheal tube may obscure the view of the oral cavity and impede access for adequate oral care 4. Moreover, nurses are often reluctant to administer oral care for fear of dislodging the endotracheal tube 4. Finally, the oral tracheal tube may, by holding the mouth open, predispose to xerostomia, an important contributory factor to poor oral hygiene 5.

Since all of these problems are obviated by tracheotomy, we would postulate that improved oral care also contributed to the reduction in ventilator-associated pneumonia seen in these patients.

REFERENCES

1. Nseir S, Di Pompeo C, Jozefowicz E, et al. Relationship between tracheotomy and ventilator-associated pneumonia: a case–control study. Eur Respir J 2007;30:314–320.[Abstract/Free Full Text]
2. El-Solh AA, Pietrantoni C, Bhat A, et al. Colonization of dental plaques: a reservoir of respiratory pathogens for hospital acquired pneumonia in institutionalized elders. Chest 2004;126:1575–1582.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
3. Schleder B, Stott K, Lloyd RC. The effect of a comprehensive oral care protocol on patients at risk for ventilator associated pneumonia. J Advocate Health Care 2002;4:27–30.
4. McNeill HE. Biting back at poor oral hygiene. Intensive Crit Care Nurs 2000;16:367–372.[CrossRef][Medline] [Order article via Infotrieve]
5. Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care 2004;13:25–33.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Permissions Request Permissions Services Email this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Frost, P. Articles by Wise, M. P. Search for Related Content PubMed PubMed Citation Articles by Frost, P. Articles by Wise, M. P.