Predisposing Factors for Nosocomial Pneumonia in Patients Receiving Mechanical Ventilation and Requiring Tracheotomy

doi:10.1378/chest.118.3.767

Chest

Volume 118, Issue 3, September 2000, Pages 767-774

https://doi.org/10.1378/chest.118.3.767 Get rights and content

Study objectives

To assess the incidence of nosocomialpneumonia (NP) after tracheotomy in an ICU population and to determine, NP risk factors during the ICU stay, particularly on the day oftracheotomy.

Design

A retrospective study usingprospectively collected data.

Setting

A 16-bedmultidisciplinary ICU.

Patients

One hundredthirty-five patients requiring tracheotomy for mechanical ventilation(MV) weaning.

Results

The mean (± SD) duration of, MV before tracheotomy was 17.8 ± 13.4 days. Thirty-seven casesof NP occurred in 35 patients (25.9%), 8.7 ± 7.3 days afterthe tracheotomy procedure. NP cases were classified as early NP(n = 19) if they occurred within 5 days after the procedure (mean,2.7 ± 1.1 days), and as late NP (n = 18) if they occurred beyondthe fifth day (mean, 14.4 ± 6.1 days). Multivariate analysisidentified the following three independent factors associated withearly NP: the presence of positive endotracheal aspirates (EAs) withpathogen levels of ≥ 10⁵ cfu/mL (p = 0.0001);hyperthermia (temperature, ≥ 38.3°C; p = 0.002) on the day oftracheotomy; and the continuation of sedation beyond 24 h afterthe tracheotomy (p = 0.0001). Accountable pathogens of early NP werepresent in EA on the day of tracheotomy (p = 0.001). Cases of late NPwere significantly associated with the duration of sedation before theprocedure (p = 0.002) and with hyperthermia (temperature,≥38.3°C) on the day of tracheotomy (p = 0.0005). The ICUadmitting diagnosis, previous NP, duration of administration ofantimicrobial agents and MV before tracheotomy, indication fortracheotomy, Po₂/fraction of inspired oxygenratio, and use of steroids on the day of the procedure were notassociated with the occurrence of NP. The mortality rate of ourpopulation was 33.3%, and NP increased this percentage to 54.3%.

Conclusions

Our results could suggest that tracheotomyshould be delayed in mechanically ventilated patients with bronchialcolonization and hyperthermia, when sedation cannot be discontinuedafter the procedure, to prevent occurrence of early, NP.

Section snippets

Study Location and Patients

The study was conducted in a 16-bed multidisciplinary ICU ( Lille University Infectious Diseases Department, set in a general hospital).All patients requiring tracheotomy during the ICU stay were eligiblefor the study. Patients were entered into the investigation if theywere > 18 years old and were excluded if the tracheotomy had beenperformed before admission into our ICU.

Study Design

A 7-year retrospective study, using prospectively collected datafrom January 1990 to December 1996, was performed. The

Patients Before Tracheotomy

A total of 1,270 patients received MV in our unit during thestudy period. Among these patients, 135 (10.6%) required atracheotomy. The mean age was 64.1 ± 14.1 years (range, 19 to 88years), and the mean SAPS I was 14.4 ± 4.8 (range, 3 to 26).Ninety-five patients (70.4%) were men. COPD was observed in 82patients (60.7%). ICU admission diagnoses included exacerbation of, COPD (n = 46), community-acquired pneumonia (n = 32), neurologicdisturbances (n = 31), nonsurgical trauma (n = 7), ARDS (n =

Discussion

The main findings of this study are as follows: (1)ventilator-associated pneumonia (VAP) occurred in 25% ofpatients requiring tracheotomy for MV weaning; (2) two groups ofpatients with pneumonia can be distinguished after tracheotomyprocedure: early pneumonia, which occurs within 5 days aftertracheotomy, and late pneumonia, which occurs beyond 8 days aftertracheotomy; (3) on the day of tracheotomy, the presence of pathogensin EAs, hyperthermia (temperature, ≥ 38°C), and the continuation

References (26)

R Celis et al.
Nosocomial pneumonia: a multivariate analysis of risk and prognosis
Chest
(1988)
AS Cross et al.
Role of respiratory assistance devices in endemic nosocomial pneumonia
Am J Med
(1981)
MH Kollef et al.
Patient transport from intensive care increases the risk of developing ventilator-associated pneumonia
Chest
(1997)
AL Plummer et al.
Consensus conference on artificial airways in patients receiving mechanical ventilation
Chest
(1989)
G Teasdale et al.
Assessment of coma and impaired consciousness
Lancet
(1974)
M Bonten et al.
The stomach is not a source for the colonization of the upper respiratory tract and pneumonia in ICU patients
Chest
(1994)
R Haley et al.
Nosocomial infections in US hospitals,1975–1976: estimated frequency by selected characteristics of patients
Am J Med
(1981)
DE Craven et al.
Preventing nosocomial pneumonia: state of the art and perspectives for the 1990s
Am J Med
(1991)
A Torres et al.
Incidence, risk and prognosis factors of nosocomial pneumonia in mechanically ventilated patients
Am Rev Respir Dis
(1990)
JL Rodriguez et al.
Early tracheostomy for primary airway management in the surgical critical care setting
Surgery
(1990)

I Lesnik et al.

The role of early tracheostomy in blunt, multiple organ trauma

Ann Surg

(1992)

WR McCabe et al.

Gram-negative bacteremia: etiology and ecology

Arch Intern Med

(1962)

JR Le Gall et al.

A simplified acute physiology score for ICU patients

Crit Care Med

(1984)

Cited by (71)

Evaluation of the microbiological efficacy of cleaning agents for tracheostomy inner cannulas
2024, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Biofilms are a significant cause of morbidity in patients with indwelling medical devices. Biofilms pose a potential risk with reusable inner cannulas by increasing the risk of infections. Effective decontamination is thus vital in decreasing bioburden. The current guidelines for cleaning inner cannulas are varied, with multiple techniques being recommended, which are not supported by strong evidence. This randomized, controlled, cross-over study attempted to enumerate the bacterial count of inner cannulas used in tracheostomy patients (n = 60) pre-and post-decontamination with detergent (A) or sterile water (B).
The patients were randomly allocated to sequence A > B or B > A in 1:1 fashion. The saline flushing of the inner cannulas was plated on trypticase soy agar with 5 % sheep blood to enumerate the bacterial count.
The mean ratio [Log (CFU)_post/Log (CFU)_pre]_A/[Log (CFU)_post/Log (CFU)_pre]_B based on 53 samples was 0.918 ± 0.470, two-sided 90 % confidence interval (CI) 0.812, 1.024. The equivalence criterion was met as the mean ratio after cleaning fell within the equivalence region of 0.8 and 1.25.
This study demonstrated the microbiological efficacy of both detergent and sterile water in the decontamination of inner cannulas, and that sterile water was not less effective than detergent in reducing the bacterial load for safe re-use of inner cannulas. This has the potential to promote cost savings for patients with tracheostomy, both in the hospital and the community. The study findings may also be relevant in formulating tracheostomy care policies.
Level of evidence: 1.
Bedside open tracheostomy at intensive care unit-our experiences of 1000 cases at a tertiary care teaching hospital of eastern India
2017, Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Citation Excerpt :
Tracheostomy is better tolerated than oral intubation and reduce sedation requirement and duration in the ICU.7 Bed side or OR open tracheostomy or bedside PDT have similar clinical indications such as protection of the larynx and upper airways, as well as weaning from prolonged mechanical ventilation.8 Bed side tracheostomy takes less time to perform the procedure with low morbidity.
Tracheostomy is usually done on critically ill patients those requiring prolonged mechanical ventilation at the intensive care unit (ICU). Bedside tracheostomy is often helpful for avoiding transferring the unstable patients to operation theater and also minimizing the cost.
Assessing the safety, cost and procedure time, complications of bedside open tracheostomy at intensive care unit considering comparison to open tracheostomy at operation theater and bedside percutaneous dilatational tracheostomy (PDT) with its complications, cost and its simplicity.
This descriptive retrospective study was carried out at a tertiary care teaching hospital during December 2006 to January 2016. It included 1000 patients, undergone open bedside tracheostomy along with 152 undergone open tracheostomy at operating room(OR) and 112 bedside PDT. All these patients were undergone bedside tracheostomy, followed up for next 3 months. Complications occurring during and after tracheostomy were documented.
This study group comprised patients with age group of 8 years to 82 years. The complications among open bed side tracheostomy within 30 days were 10 minor bleeding, 1 major bleeding, 2 cardiac arrest, 1 pneumothorax, 6 stomal sepsis, 5 cervical emphysema. Late complications like 2 laryngotracheal stenosis (LTS) were seen where as other complication like tracheocutaneous fistula and tracheoinominate fistula were not observed. The complications rate is less in bedside open tracheostomy than open tracheostomy at OR and bedside PDT in our study.
Bedside elective open tracheostomy is safe, effective, cost effective and allowing timely tracheostomy with low morbidity.
Resuscitating the tracheostomy patient in the ED
2016, American Journal of Emergency Medicine
Emergency physicians must be masters of the airway. The patient with tracheostomy can present with complications, and because of anatomy, airway and resuscitation measures can present several unique challenges. Understanding tracheostomy basics, features, and complications will assist in the emergency medicine management of these patients.
The aim of this review is to provide an overview of the basics and features of the tracheostomy, along with an approach to managing tracheostomy complications.
This review provides background on the reasons for tracheostomy placement, basics of tracheostomy, and tracheostomy tube features. Emergency physicians will be faced with complications from these airway devices, including tracheostomy obstruction, decannulation or tube dislodgement, stenosis, tracheoinnominate fistula, and tracheoesophageal fistula. Critical patients should be evaluated in the resuscitation bay, and consultation with ENT should be completed while the patient is in the department. This review provides several algorithms for management of complications. Understanding these complications and an approach to airway management during cardiac arrest resuscitation is essential to optimizing patient care.
Tracheostomy patients can present unique challenges for emergency physicians. Knowledge of the basics and features of tracheostomy tubes can assist physicians in managing life-threatening complications including tube obstruction, decannulation, bleeding, stenosis, and fistula.
Adult spontaneous and conventional mechanical ventilation
2013, Tidy's Physiotherapy: Fifteenth Edition
Successful prevention of tracheostomy associated pneumonia in step-down units
2011, American Journal of Infection Control
Citation Excerpt :
Recent studies have shown significant benefits in early tracheostomy in terms of improving clinical outcomes, reducing duration of mechanical ventilation, reduction in ICU stay and VAP, reduction of sedation use, and early mobilization of these patients. Most authors believe that tracheostomy provides greater comfort for the critically ill patient when compared with tracheal intubation because of the possibility of communication, oral ingestion, better oral hygiene, ease of weaning from mechanical ventilation, and decrease in respiratory work and airway resistance.12 The long-term ventilated patient is at high risk for nosocomial pneumonia and tracheobronchitis.
Prevention of health care-associated infections is well described in critical care. However, surveillance in step-down unit (SDU) patients who need intermediate care with bilevel mechanical ventilation pressure through tracheotomy needs to be better understood. We evaluated the implementation of preventive measures in SDU over 2 different periods on device (bilevel mechanical ventilation)-associated pneumonia.
A quasi-experimental, interrupted time series study was conducted in SDUs. Interventions were implemented to optimize the prevention of pneumonia associated with tracheostomy and evaluated in 2 phases. From January to October of 2007 (phase 1), some practices recommended by the Centers for Disease Control and Prevention were implemented, and the epidemiology unit carried out surveillance for pneumonia associated with tracheostomy. From November of 2007 to August of 2008 (phase 2) the same practices recommended by the Centers for Disease Control and Prevention were followed, but, in addition, the assessment of these processes as well as bedside interventions were initiated.
The mean incidence density of tracheostomy associated pneumonia per 1,000 tracheostomy-days in the SDUs was 6.0 in phase 1 and 0.7 in phase 2, P = .002.
Reducing pneumonia associated with tracheostomy is a continuous multidisciplinary process that involves the measurement of multiple performance metrics.
Comparison of Outcomes of Early Versus Late Tracheostomy in the Treatment of Mechanically Ventilated Critically ill Patients
2023, Indian Journal of Otolaryngology and Head and Neck Surgery

View all citing articles on Scopus

View full text

Chest

Clinical Investigations in Critical CarePredisposing Factors for Nosocomial Pneumonia in Patients Receiving Mechanical Ventilation and Requiring Tracheotomy

Study objectives

Design

Setting

Patients

Results

Conclusions

Section snippets

Study Location and Patients

Study Design

Patients Before Tracheotomy

Discussion

Chest

Am J Med

Chest

Chest

Lancet

Chest

Am J Med

Preventing nosocomial pneumonia: state of the art and perspectives for the 1990s

Am J Med

Incidence, risk and prognosis factors of nosocomial pneumonia in mechanically ventilated patients

Am Rev Respir Dis

Early tracheostomy for primary airway management in the surgical critical care setting

Surgery

The role of early tracheostomy in blunt, multiple organ trauma

Ann Surg

Gram-negative bacteremia: etiology and ecology

Arch Intern Med

A simplified acute physiology score for ICU patients

Crit Care Med

Clinical Investigations in Critical Care
Predisposing Factors for Nosocomial Pneumonia in Patients Receiving Mechanical Ventilation and Requiring Tracheotomy