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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