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From the authors

E. Kostadima, A. Kaditis, E. Alexopoulos, E. Zakynthinos, D. Sfyras
European Respiratory Journal 2006 27: 437-438; DOI: 10.1183/09031936.06.00127405
E. Kostadima
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A. Kaditis
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E. Alexopoulos
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E. Zakynthinos
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We read with interest the letter from S. Teramoto and coworkers regarding the role of oropharyngeal dysphagia in the pathogenesis of ventilator-associated pneumonia (VAP). The presence of a nasogastric tube has been identified as an independent risk factor for VAP, mainly because of gastro-oesophageal reflux and aspiration 1, 2. Aspiration is probably due to loss of anatomical integrity of the lower oesophageal sphincter, increased frequency of transient sphincter relaxation and oropharyngeal dysphagia via desensitisation of the pharyngoglottal adduction reflex 3, 4.

We speculate that the advantage of performing an early gastrostomy is the possibility of avoiding dysfunction of lower oesophageal sphincter due to the presence of a nasogastric tube 5. Johnson et al. 6 have demonstrated an increase in lower oesophageal sphincter pressure following performance of percutaneous endoscopic gastrostomy and a decrease in gastro-oesophageal reflux score. Prevention of oropharyngeal dysphagia induced by the nasogastric tube may be another mechanism in reducing the risk of aspiration.

Of note, percutaneous endoscopic gastrostomy does not eliminate gastro-oesophageal reflux, mainly in patients with a pre-existing nasogastric tube 7. For this reason, we selected the performance of early gastrostomy in our study. In a recent report, McClave et al. 8 found a decrease in the incidence of regurgitation in intensive care unit patients with early gastrostomy compared with those with a nasogastric tube.

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    References

    1. ↵
      Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of the CDC and the Health-care Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53:1–36.
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    2. ↵
      Chastre J, Fagon J-Y. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867–903.
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    3. ↵
      Gomes GF, Pisani JC, Macedo ED, Campos AC. The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia. Curr Opin Clin Nutr Metab Care 2003;6:327–333.
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    4. ↵
      Nind G, Chen W, Protheroe R, et al. Mechanisms of gastroesophageal reflux in critically ill mechanically ventilated patients. Gastroenterology 2005;128:600–606.
      OpenUrlCrossRefPubMedWeb of Science
    5. ↵
      Kostadima E, Kaditis AG, Alexopoulos EI, Zakynthinos E, Sfyras D. Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients: a preliminary study. Eur Respir J 2005;26:106–111.
      OpenUrlAbstract/FREE Full Text
    6. ↵
      Johnson DA, Hacker JF, Benjamin SB, et al. Percutaneous endoscopic gastrostomy effects on gastroesophageal reflux and the lower esophageal sphincter. Am J Gastroenterol 1987;82:622–624.
      OpenUrlPubMedWeb of Science
    7. ↵
      Lien HC, Chang CS, Chen GH. Can percutaneous endoscopic jejunostomy prevent gastroesophageal reflux in patients with pre-existing esophagitis? Am J Gastroenterol 2000;95:3439–3443.
      OpenUrlCrossRefPubMedWeb of Science
    8. ↵
      McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med 2005;33:324–330.
      OpenUrlCrossRefPubMedWeb of Science
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    E. Kostadima, A. Kaditis, E. Alexopoulos, E. Zakynthinos, D. Sfyras
    European Respiratory Journal Feb 2006, 27 (2) 437-438; DOI: 10.1183/09031936.06.00127405

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    From the authors
    E. Kostadima, A. Kaditis, E. Alexopoulos, E. Zakynthinos, D. Sfyras
    European Respiratory Journal Feb 2006, 27 (2) 437-438; DOI: 10.1183/09031936.06.00127405
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