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The tracheal tube: gateway to ventilator-associated pneumonia.
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PMID:  21996487     Owner:  NLM     Status:  MEDLINE    
Ventilator-associated pneumonia (VAP) is a major healthcare-associated complication with considerable attributable morbidity, mortality and cost. Inherent design flaws in the standard high-volume low-pressure cuffed tracheal tubes form a major part of the pathogenic mechanism causing VAP. The formation of folds in the inflated cuff leads to microaspiration of pooled oropharyngeal secretions into the trachea, and biofilm formation on the inner surface of the tracheal tube helps to maintain bacterial colonization of the lower airways. Improved design of tracheal tubes with new cuff material and shape have reduced the size and number of these folds, which together with the addition of suction ports above the cuff to drain pooled subglottic secretions leads to reduced aspiration of oropharyngeal secretions. Furthermore, coating tracheal tubes with antibacterial agents reduces biofilm formation and the incidence of VAP. In this Viewpoint article we explore the published data supporting the new tracheal tubes and their potential contribution to VAP prevention strategies. We also propose that it may now be against good medical practice to continue to use a 'standard cuffed tube' given what is already known, and the weight of evidence supporting the use of newer tube designs.
Parjam S Zolfaghari; Duncan L A Wyncoll
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Publication Detail:
Type:  Journal Article     Date:  2011-09-29
Journal Detail:
Title:  Critical care (London, England)     Volume:  15     ISSN:  1466-609X     ISO Abbreviation:  Crit Care     Publication Date:  2011  
Date Detail:
Created Date:  2012-03-28     Completed Date:  2012-08-22     Revised Date:  2013-06-27    
Medline Journal Info:
Nlm Unique ID:  9801902     Medline TA:  Crit Care     Country:  England    
Other Details:
Languages:  eng     Pagination:  310     Citation Subset:  IM    
London Deanery, Guy's and St Thomas' NHS Trust, Lambeth Palace Road, London SE1 7EH, UK.
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MeSH Terms
Cross Infection / etiology,  prevention & control*
Equipment Design
Intensive Care Units
Intubation, Intratracheal / adverse effects,  instrumentation*
Pneumonia, Ventilator-Associated / etiology,  prevention & control*
Comment In:
Crit Care. 2011;15(6):459; author reply 459   [PMID:  22152104 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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Journal Information
Journal ID (nlm-ta): Crit Care
Journal ID (iso-abbrev): Crit Care
ISSN: 1364-8535
ISSN: 1466-609X
Publisher: BioMed Central
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Copyright ©2011 BioMed Central Ltd
Print publication date: Year: 2011
Electronic publication date: Day: 29 Month: 9 Year: 2011
pmc-release publication date: Day: 29 Month: 9 Year: 2012
Volume: 15 Issue: 5
First Page: 310 Last Page: 310
ID: 3334734
Publisher Id: cc10352
PubMed Id: 21996487
DOI: 10.1186/cc10352

The tracheal tube: gateway to ventilator-associated pneumonia
Parjam S Zolfaghari1 Email:
Duncan LA Wyncoll2 Email:
1London Deanery, Guy's and St Thomas' NHS Trust, Lambeth Palace Road, London SE1 7EH, UK
2Guy's and St Thomas' NHS Trust, Lambeth Palace Road, London SE1 7EH, UK


Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring in a mechanically ventilated patient after 48 hours of endotracheal intubation [1]. Despite significant advances in managing intubated patients, VAP remains a common and occasionally fatal complication in the ICU [2]. A systematic review of published data since 1990 showed the incidence of VAP to be 10 to 20%, with a possible two-fold increase in mortality attributable to VAP [3]. The ICU length of stay was also significantly increased by a mean of 6.1 days with an attributable cost of $10,019 per case [3]. A recent Canadian study estimated an additional 4.3 ICU days attributable to VAP, occupying 2% of all ICU days and an estimated national cost of CAN$43 million per year [4]. Similar findings were reported by a North American study with increased unadjusted ICU length of stay and mortality in patients with VAP (50% mortality in VAP patients versus 34% in non-VAP) with an estimated $11,897 attributable cost [5]. Furthermore, the burden of VAP takes up a significant portion of antibiotic dispensing in the ICU [6] and may well be a contributor to the development of multi-resistant bacteria [7].

Importantly, many units are recently reporting a reduction in VAP incidence following implementation of various prevention measures, as well as programs that increase compliance with such care bundles [8-10].


The pathogenesis of VAP mainly stems from the introduction of microbial pathogens by microaspiration past the tracheal tube cuff and into the lower respiratory tract (Figure 1). Subsequent colonization and overwhelming of the host mechanical, humoral and cellular defence mechanisms lead to the development of VAP [11]. The tracheal tube forms the essential first part of this mechanistic pathway by breeching the anatomic barriers formed by the glottis and larynx. Suppression of the cough reflex as a result of sedation further hampers natural reflexes [2]. The oropharynx, nasal sinuses and the stomach have been proposed as potential reservoirs of infective material [11]. Furthermore, bacterial biofilm formation on the inner aspect of the tracheal tube is another potential portal of bacteria [12]. But perhaps more importantly, this biofilm formation, which takes place within days of intubation, functions to maintain bacterial colonization of the trachea [13]. The biofilm is inaccessible to antibiotic therapy unless aerosolised, which likely reduces bacterial shedding, but does not lead to full eradication and may even promote antibiotic resistance [14]. The fact that the NASCENT trial, using a silver-coated tracheal tube, showed a significant reduction in microbiologically diagnosed VAP suggests that intraluminal biofilm and the intratracheal route of infection contribute significantly to the aetiology of VAP [15].

This article explores the contribution of the tracheal tube to the development of VAP and looks at how the emergence of new designs may help prevent this complication. A question is posed: is it good medical practice to continue to use a 'standard cuffed tube' given what is already known?

The contribution of the tracheal tube cuff

The main function of the tracheal tube cuff is to produce a seal between the tube and the tracheal mucosa in order to allow the institution of positive pressure ventilation. It has become apparent, however, that pooling and leakage around the endotracheal tube cuff leads to aspiration of contaminated oropharyngeal secretions, stomach contents and bacteria into the trachea and the lower respiratory tract [16]. This is supported by the finding that persistent intra-cuff pressures of < 20 cmH2O in intubated patients are independently associated with pneumonia [17]. Furthermore, frequent microaspiration of stomach contents as evidenced by the presence of pepsin in sequential tracheal aspirates is an independent predictor of pneumonia in intubated patients [18]. These findings highlight the importance of adequate sealing of the lower respiratory tract from soiling by oropharyngeal secretions.

Some small studies have looked at the use of automated devices to control cuff pressures but have produced varying results. In an 'underpowered' randomised controlled trial where cuff pressures were maintained either by an automatic device at 25 to 30 cmH2O, or 8-hourly nurse-adjusted cuff pressures, no difference in the incidence of VAP was observed [19]. Conversely, a more recent proof of concept study showed reduced pepsin and micro-aspiration in the tracheal samples and lower microbiologically confirmed VAP in patients where an automated device was used to maintain cuff pressures [20].

Interestingly, despite correctly pressurised cuffs in commonly used standard high-volume low-pressure tubes, microaspiration often takes place [21-23]. This stems from the basically flawed design of these cuffs. The diameter of the fully inflated cuff is up to twice as large as the diameter of the tracheal lumen, so that once inflated to the correct pressure in the trachea, these cuffs remain only partially inflated and result in the formation of folds along the cuff that then channel oropharyngeal secretions into the trachea [21]. Bench studies have clearly demonstrated these findings (Figure 2) and identified major design features that influence the size of these leaky folds and channels.

Excess cuff material and shape of the cuff

Newer tracheal tube cuff designs such as the Lo-Trach™ (Intravent) low-volume low-pressure cuff and the Micro-cuff ™ tube (Kimberly-Clark) have shown promising results with significant reduction in leakage of fluid placed above the cuffs [24-26]. The Microcuff™ tube has an elongated cylindrical-shaped cuff that results in a fully inflated cuff in situ with minimal excess cuff material at acceptable intracuff pressures of 20 to 30 cmH2O. The fully inflated cuff leads to limited or even absence of channel formation and the shape of the cuff results in a larger surface area in contact with the trachea. Microaspiration of blue dye placed above the cuff (as demonstrated by bronchoscopy) was also shown to be reduced and delayed in patients intubated with the Mallinckrodt/Covidien SealGuard™ tube with an inverted pear-shaped (conical) cuff [27]. This pear-shaped design was first described in 1999 by Young and Blunt [28], and subsequently shown to provide better sealing properties across a wider range of tracheal diameters when compared to the cylindrical-shaped cuff [29].

Tracheal tube cuff material

A major advance in the tracheal tube cuff design has been the introduction of thinner (7 μm thick) polyurethane (PU) material [29]. These cuffs have consistently been shown to form narrower folds/channels with reduced leakage than tubes with thicker (50 μm) polyvinyl chloride (PVC) cuffs [21,25,30]. Clinical studies have also confirmed reduced leakage of subglottic material [27], reduced pepsin levels in tracheal secretions [31], and lower rates of nosocomial post-operative pneumonia in patients following cardiac surgery randomised to endotracheal tubes with cuffs made from PU [32]. A retrospective analysis of intubated patients following the introduction of tracheal tubes with PU cuffs showed a reduction in VAP from 5.3 to 2.8 per 1,000 ventilator days [33]. In an elegant in vitro study of six commercially available tracheal tubes, Zanella and colleagues [30] showed that all cuffs made from PVC (be they conical or cylindrical in shape) demonstrated significant leakage over a 24-hour period, except when a positive end-expiratory pressure (PEEP) of 15 cmH2O was applied in addition. On the other hand, double-layered cuffs made of Guayule-latex and PU cuffs provided significantly improved performances with minimal leakage at zero PEEP and none at 5 cmH2O. Interestingly, there was no difference in performance between the cylindrical and conically shaped cuffs made from PU (Microcuff™, cylindrical versus Mallinckrodt/Covidien SealGuard™, conical).

Subglottic secretion drainage and ventilator-associated pneumonia

Removal of oropharyngeal secretions that have pooled above the tracheal tube cuff by subglottic secretion drainage (SSD) further reduces microaspiration [34-37] (Figure 3). Specially designed tracheal tubes are widely available, with a separate lumen or lumens that open above the cuff and allow intermittent or continuous drainage of the pooled secretions. In 2005, a meta-analysis examining five prospective studies using SSD showed a 50% reduction in the incidence of pneumonia in patients randomised to SSD [38]. This effect was more pronounced in those who were intubated for more than 72 hours and for early onset VAP. A reduction in the length of mechanical ventilation and ICU stay (2 and 3 days, respectively) makes this a favourable intervention, and has now been included in many national VAP prevention bundles [39]. Further convincing evidence has also been published since this 2005 meta-analysis [34,36,37].

However, the uptake of SSD into clinical practice has been slow [40], and this is likely because of (i) conflicting clinical trial evidence, (ii) safety concerns surrounding laryngeal/tracheal damage caused by the stiffer nature of these tubes, (iii) suction damage to the tracheal mucosa, (iv) the higher cost of the tubes, and (v) the fact that the studies often only show that early VAP is reduced. Of nine prospective, randomised controlled studies of SSD, six did not look at adverse effects of SSD, two reported no adverse events and one reported a significant increase in the risk of laryngeal oedema requiring re-intubation in patients intubated with an SSD tube [13,41]. Furthermore, Dragoumanis and colleagues [42] described herniation of tracheal mucosa into the dorsal SSD suction port of the first generation Hi-Lo® Evac endotracheal tube (Hi-Lo Evac, Mallinckrodt, Athlone, Ireland), resulting in failure of subglottic suction and the risk of mucosal injury due to tissue ischaemia. Of concern also is the fact that in sheep, significant tracheal mucosal injury has been observed with continuous aspiration of subglottic secretions [43].

These observations have encouraged the development of second and third generation tube designs, which have overcome some of these concerns. In some tubes the position of the SSD suction port has been placed adjacent to the tracheal tube cuff, lifting its opening away from the tracheal mucosa. Also, improved cuff designs that pro-duce a better tracheal seal (tapered/conical PU or lowvolume controlled-pressure cuffs) have allowed hourly intermittent suctioning, instead of continuous suction [37]. Avoiding continuous suctioning strongly suggests that ischaemic lesions of the posterior tracheal wall can now be avoided. The LoTrach™ tube has further addressed these concerns by incorporating three subglottic suction ports adjacent to the tracheal tube cuff, making subglottic suctioning more efficient and less traumatic. Further-more, its flexible design conforms to the shape of the upper airway, potentially reducing laryngeal injury [24].

In order to accommodate the SSD channel into the wall of the tracheal tube, the outer diameter of the tube in some of the designs has had to be enlarged by approximately 1 mm on average and some designs are slightly stiffer. This needs to be taken into consideration when sizing these tracheal tubes in order to avoid laryngeal injuries, and is a potential area for future refinement in design.

Tracheal tube biofilm management

Microbial biofilms are present on the luminal surface of endotracheal tubes of all patients ventilated in the ICU and form within hours of tracheal intubation, becoming abundant at 96 hours [12,44,45]. Whilst the exact sequence of tube colonisation and infection is unclear, it is thought that the microbial biofilm may act as a reservoir of pathogens causing recurrent infections [45]. Adair and colleagues [12] showed that 70% of patients with VAP had the identical pathogen isolated from their tracheal tube and lower respiratory tract. Furthermore, biofilms are associated with developing microbial bacterial resistance [46].

Endotracheal tubes coated with anti-microbial silver hygrogel showed delayed and reduced bacterial colonisation in a mechanically ventilated animal model [47]. In one of the largest multicentre prospective studies of VAP prevention (NASCENT study), Kollef and colleagues [15] compared rates of VAP in 2,003 patients randomised to intubation with either a silver-coated tube (Agento IC, CR Bard Inc., Covington, GA, USA) or the Hi-Lo Endotracheal Tube (Mallinckrodt, St Louis, MO, USA). This study showed a statistically significant relative risk reduction of 36% in the occurrence of VAP in patients intubated with silvercoated tubes, but failed to show a reduction in length of mechanical ventilation, ICU stay or mortality. Interestingly, the VAP rates in this study were lower than previously quoted rates (5 to 10% versus the 10 to 20% in other studies frequently quoted).

Tracheotomies and ventilator-associated pneumonia

Another frequently debated point is the influence of the timing of tracheotomy on the development of VAP. While Rumbak and colleagues [48] showed a significant reduction in the development of VAP with early tracheotomy (within 48 hours of mechanical ventilation) versus delayed tracheotomy (after 14 to 16 days), a later but larger multicentre study showed no difference in the rate of pneumonia in patients that underwent early tracheotomy versus patients who had more prolonged endotracheal intubation [49]. The largest multicentre study on this question showed no difference in the incidence of VAP with early tracheotomy (after 6 to 8 days of tracheal intubation) versus later tracheotomy (after 13 to 15 days) [50]. One interpretation of these observations is that while a patient has any artificial cuffed airway in place (whether endotracheal or tracheostomy tube), this pre-disposes to some degree of microaspiration and biofilm formation on the inner lumen, which increases the risk for VAP. However, many of the novel design features already mentioned are also now being incorporated into new tracheostomy tubes.

Other strategies

It is clear that reducing the incidence of VAP requires new strategies incorporating guidelines, resources, education and leadership [51,52]. Patient positioning, sedation holds, adequate and frequent oral hygiene, SSD, maintenance of cuff pressures and guidelines on stress ulcer prophylaxis are listed in a high impact care bundle to prevent VAP that has recently been published [39]. The integration of new and proven technology into this strategy will further improve its success. Current evidence highlighting the role of tracheal tubes in the pathogenic processes leading to the development of VAP may be ethically difficult to ignore. The newer tracheal tubes with tapered or cylindrical cuffs made from thin PU material and incorporating subglottic ports for intermittent suction of subglottic secretions should be an addition to this VAP bundle. Furthermore, automating cuff pressures using devices such as the disposable Portex PressureEasy® cuff controller or the Venner™ PneuX PY™, comprising the Venner tracheal seal monitor device in conjunction with the LoTrach™ ET Tube and LoTrach™ T Tube, would limit exposure to low (< 20 cmH2O) and high (> 30 cmH2O) cuff pressures (that is, by continuous monitoring and maintaining of cuff pressure). Interestingly, in a study discussed earlier, using a constant cuff pressure controller device failed to show statistically significant reduction in VAP when compared to an 8-hourly nurse monitored method (22% VAP in intervention group versus 29% in control group) [19]. However, the investigators used the leaky PVC high-volume low-pressure cuffed tubes for both groups, and highlight the point that using single interventions to reduce VAP is unlikely to be as successful as multiple interventions [53].

Attributable mortality and ventilator-associated pneumonia

Some clinicians remain concerned about the lack of effect on mortality in the published studies of VAP reduction interventions. Mortality is clearly the hardest end-point for clinical trials in the critically ill, but softer outcomes such as VAP should not be ignored [54]. It is important to distinguish the consequences of VAP from the progression of an underlying illness, and a key variable is the attributable mortality of developing VAP. The literature is not clear in answering this question, since it may well depend on the severity of underlying disease and acute respiratory failure as a result of pneumonia [55,56], the case-mix of the population [57], the adequacy of initial empiric treatment [58], and the infecting agent [59]. Methodological differences, such as variables and covariates used to match control patients in the various studies, add to this uncertainty [3].

The attributable mortality of VAP is widely quoted as 0 to 36% [60-63]. By way of illustration, let us consider a hypothetical VAP trial involving 800 patients, and a pro-posed new intervention that reduces VAP by 50%. In this population the control arm event rate (VAP) is about 20%, and the 28-day mortality is also about 20%. If the trial showed that VAP was reduced to 10% in the intervention arm (a 50% reduction), and if it was assumed that the attributable mortality due to VAP is about 10%, then at very best mortality could only be reduced by a statistically non-significant (but clinically important) four patients. Hence the reason why so many of the current studies are not powered for mortality.

Should the newer tubes be used for all intubated patients admitted to the ICU?

The incidence of VAP increases with length of mechanical ventilation [64,65], and the evidence presented above points towards more benefit being gained by patients intubated for prolonged periods [15,38]. Various tools have been proposed to predict length of mechanical ventilation, but these are only applicable at 24 to 48 hours following institution of mechanical ventilation [66,67]. It could therefore be argued as reasonable to intubate all patients admitted to the ICU who are expected to be intubated for longer than 24/48 hours with a newer generation tracheal tube.

Can we justify the higher cost of the newer tubes?

When compared to the old generation (leaky) tubes without subglottic suction, which cost about $2 each, and considering that each new case of VAP leads to an increased estimated cost of approximately $5,000 to $26,000 [5], then it would be financially beneficial to pay a lot more for the 'interface' (that is, the tube) between the ventilator and the patient - an 'interface' that can potentially contribute to or prevent VAP. A cost-analysis performed by Shorr and colleagues [68] found a $12,840 reduction in hospital costs per single case of VAP prevented as a result of introducing $90 silver-coated tubes compared to using standard $2 non-coated tubes, making this a very financially viable intervention. In fact, the break-even cost of the silver-coated tubes was calculated to be $388. Even 'back of the envelope' conservative calculations that assume the cost of a VAP to be just $5,000 would support an investment of $49 per patient in a new intervention if it merely reduces the rate of VAP by just 1% absolute!


In a recent editorial, Valles, Blanch and Respiratorias [69] applied Sutton's law to interventions that prevent VAP. Willy Sutton was a prolific bank robber, having stolen $2 million over his career. When asked by a reporter why he continued to rob banks, he replied, 'Because that is where the money is'. Application of Sutton's law - 'Go where the money is' - to the paradigm of VAP prevention strongly favours multi-faceted strategies aimed at reducing aspiration of oropharyngeal secretions. With the increasing weight of evidence pointing at the role of the tracheal tube design and maintenance of adequate cuff pressures, is it really good medical practice to continue to use 'standard cuffed tubes'?


PEEP: positive end-expiratory pressure; PU: polyurethane; PVC: polyvinyl chloride; SSD: subglottic secretion drainage; VAP: ventilator-associated pneumonia.

Competing interests

PSZ has no competing interests. In the past 3 years, DW has acted as a paid consultant or given lectures on VAP for Covidien, Kimberly-Clark and Bard.


We would like to thank Dr Peter Young for advice in writing the manuscript and for supplying the photographs displayed in Figure 2.

Kollef MH,What is ventilator-associated pneumonia and why is it important?Respir CareYear: 200550714721 discussion 721-714. 15913464
Chastre J,Fagon J-Y,Ventilator-associated pneumoniaAm J Respir Crit Care MedYear: 200216586790311934711
Safdar N,Dezfulian C,Collard HR,Saint S,Clinical and economic consequences of ventilator-associated pneumonia: a systematic reviewCrit Care MedYear: 2005332184219310.1097/01.CCM.0000181731.53912.D916215368
Muscedere JG,Martin CM,Heyland DK,The impact of ventilator-associated pneumonia on the Canadian health care systemJ Crit CareYear: 20082351010.1016/j.jcrc.2007.11.01218359415
Warren DK,Shukla SJ,Olsen MA,Kollef MH,Hollenbeak CS,Cox MJ,Cohen MM,Fraser VJ,Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical centerCrit Care MedYear: 2003311312131710.1097/01.CCM.0000063087.93157.0612771596
Bergmans DC,Bonten MJ,Gaillard CA,van Tiel FH,van der Geest S,de Leeuw PW,Stobberingh EE,Indications for antibiotic use in ICU patients: a one-year prospective surveillanceJ Antimicrob ChemotherYear: 19973952753510.1093/jac/39.4.5279145828
Klompas M,Prevention of ventilator-associated pneumoniaExpert Rev Anti Infect TherYear: 2010879180010.1586/eri.10.5920586564
Hawe CS,Ellis KS,Cairns CJS,Longmate A,Reduction of ventilator-associated pneumonia: active versus passive guideline implementationIntensive Care MedYear: 2009351180118610.1007/s00134-009-1461-019308354
Bird D,Zambuto A,O'Donnell C,Silva J,Korn C,Burke R,Burke P,Agarwal S,Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unitArch SurgYear: 201014546547010.1001/archsurg.2010.6920479345
Bouadma L,Mourvillier B,Deiler V,Le Corre B,Lolom I,Régnier B,Wolff M,Lucet J-C,A multifaceted program to prevent ventilator-associated pneumonia: Impact on compliance with preventive measures*Crit Care MedYear: 20103878979610.1097/CCM.0b013e3181ce21af20068461
Niederman MS,The clinical diagnosis of ventilator-associated pneumoniaRespir CareYear: 200550788796 discussion 807-712. 15913469
Adair CG,Gorman SP,Feron BM,Byers LM,Jones DS,Goldsmith CE,Moore JE,Kerr JR,Curran MD,Hogg G,Webb CH,McCarthy GJ,Milligan KR,Implications of endotracheal tube biofilm for ventilator-associated pneumoniaIntensive Care MedYear: 1999251072107610.1007/s00134005101410551961
Deem S,Treggiari MM,New endotracheal tubes designed to prevent ventilator-associated pneumonia: do they make a difference?Respir CareYear: 2010551046105520667152
Stewart PS,Costerton JW,Antibiotic resistance of bacteria in biofilmsLancetYear: 200135813513810.1016/S0140-6736(01)05321-111463434
Kollef MH,Afessa B,Anzueto A,Veremakis C,Kerr KM,Margolis BD,Craven DE,Roberts PR,Arroliga AC,Hubmayr RD,Restrepo MI,Auger WR,Schinner R,NASCENT Investigation GroupSilver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trialJAMAYear: 200830080581310.1001/jama.300.7.80518714060
Craven DE,Hjalmarson KI,Ventilator-associated tracheobronchitis and pneumonia: thinking outside the boxClin Infect DisYear: 201051Suppl 1S596620597674
Rello J,Soñora R,Jubert P,Artigas A,Rué M,Vallés J,Pneumonia in intubated patients: role of respiratory airway careAm J Respir Crit Care MedYear: 19961541111158680665
Metheny NA,Clouse RE,Chang Y-H,Stewart BJ,Oliver DA,Kollef MH,Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factorsCrit Care MedYear: 2006341007101510.1097/01.CCM.0000206106.65220.5916484901
Valencia M,Ferrer M,Farre R,Navajas D,Badia JR,Nicolas JM,Torres A,Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trialCrit Care MedYear: 2007351543154910.1097/01.CCM.0000266686.95843.7D17452937
Nseir S,Zerimech F,Fournier C,Lubret R,Ramon P,Durocher A,Balduyck M,Continuous control of tracheal cuff pressure and microaspiration of gastric contents: a randomized controlled studyCrit CareYear: 201115Suppl 115810.1186/cc957821586102
Seegobin RD,van Hasselt GL,Aspiration beyond endotracheal cuff sCan Anaesth Soc JYear: 19863327327910.1007/BF030107373719428
Young PJ,Rollinson M,Downward G,Henderson S,Leakage of fluid past the tracheal tube cuff in a benchtop modelBr J AnaesthYear: 1997785575629175972
Asai T,Shingu K,Leakage of fluid around high-volume, low-pressure cuff s apparatus A comparison of four tracheal tubesAnaesthesiaYear: 200156384210.1046/j.1365-2044.2001.01718.x11167433
Young PJ,Pakeerathan S,Blunt MC,Subramanya S,A low-volume, lowpressure tracheal tube cuff reduces pulmonary aspirationCrit Care MedYear: 20063463263910.1097/01.CCM.0000201406.57821.5B16505646
Dullenkopf A,Gerber A,Weiss M,Fluid leakage past tracheal tube cuff s: evaluation of the new Microcuff endotracheal tubeIntensive Care MedYear: 2003291849185310.1007/s00134-003-1933-612923620
Pitts R,Fisher D,Sulemanji D,Kratohvil J,Jiang Y,Kacmarek R,Variables affecting leakage past endotracheal tube cuffs: a bench studyIntensive Care MedYear: 2010362066207310.1007/s00134-010-2048-520852839
Lucangelo U,Zin WA,Antonaglia V,Petrucci L,Viviani M,Buscema G,Borelli M,Berlot G,Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unitCrit Care MedYear: 20083640941310.1097/01.CCM.0000297888.82492.3118007268
Young PJ,Blunt MC,Improving the shape and compliance characteristics of a high-volume, low-pressure cuff improves tracheal sealBr J AnaesthYear: 19998388788910700788
Dave MH,Frotzler A,Spielmann N,Madjdpour C,Weiss M,Effect of tracheal tube cuff shape on fluid leakage across the cuff: an in vitro studyBr J AnaesthYear: 201010553854310.1093/bja/aeq20220682571
Zanella A,Scaravilli V,Isgrò S,Milan M,Cressoni M,Patroniti N,Fumagalli R,Pesenti A,Fluid leakage across tracheal tube cuff, effect of different cuff material, shape, and positive expiratory pressure: a bench-top studyIntensive Care MedYear: 20113734334710.1007/s00134-010-2106-z21152894
Nseir S,Zerimech F,De Jonckheere J,Alves I,Balduyck M,Durocher A,Impact of polyurethane on variations in tracheal cuff pressure in critically ill patients: a prospective observational studyIntensive Care MedYear: 2010361156116310.1007/s00134-010-1892-720397001
Poelaert J,Depuydt P,De Wolf A,Van de Velde S,Herck I,Blot S,Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: a pilot studyJ Thorac Cardiovasc SurgYear: 200813577177610.1016/j.jtcvs.2007.08.05218374755
Miller MA,Arndt JL,Konkle MA,Chenoweth CE,Iwashyna TJ,Flaherty KR,Hyzy RC,A polyurethane cuffed endotracheal tube is associated with decreased rates of ventilator-associated pneumoniaJ Crit CareYear: 20112628028610.1016/j.jcrc.2010.05.03520655698
Lorente L,Lecuona M,Jiménez A,Mora ML,Sierra A,Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumoniaAm J Respir Crit Care MedYear: 20071761079108310.1164/rccm.200705-761OC17872488
Bouza E,Burillo A,Advances in the prevention and management of ventilator-associated pneumoniaCurr Opin Infect DisYear: 20092234535110.1097/QCO.0b013e32832d891019506478
Bouza E,Pérez MJ,Muñoz P,Rincón C,Barrio JM,Hortal J,Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgeryChestYear: 200813493894610.1378/chest.08-010318641114
Lacherade JC,De Jonghe B,Guezennec P,Debbat K,Hayon J,Monsel A,Fangio P,Appere de Vecchi C,Ramaut C,Outin H,Bastuji-Garin S,Intermittent subglottic secretion drainage and ventilator-associated pneumonia: a multicenter trialAm J Respir Crit Care MedYear: 201018291091710.1164/rccm.200906-0838OC20522796
Dezfulian C,Shojania K,Collard HR,Kim HM,Matthay MA,Saint S,Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysisAm J MedYear: 2005118111810.1016/j.amjmed.2004.07.05115639202
NHS and Department of Health care bundle to reduce ventilator associated pneumonia
Gentile MA,Siobal MS,Are specialized endotracheal tubes and heat-and-moisture exchangers cost-effective in preventing ventilator associated pneumonia?Respir CareYear: 201055184196 discussion 196-187. 20105344
Girou E,Buu-Hoi A,Stephan F,Novara A,Gutmann L,Safar M,Fagon J-Y,Airway colonisation in long-term mechanically ventilated patients. Effect of semi-recumbent position and continuous subglottic suctioningIntensive Care MedYear: 20043022523310.1007/s00134-003-2077-414647884
Dragoumanis CK,Vretzakis GI,Papaioannou VE,Didilis VN,Vogiatzaki TD,Pneumatikos IA,Investigating the failure to aspirate subglottic secretions with the Evac endotracheal tubeAnesth AnalgYear: 200710510831085 table of contents. 10.1213/01.ane.0000278155.19911.6717898392
Berra L,De Marchi L,Panigada M,Yu Z-X,Baccarelli A,Kolobow T,Evaluation of continuous aspiration of subglottic secretion in an in vivo studyCrit Care MedYear: 2004322071207810.1097/01.CCM.0000142575.86468.9B15483416
Gorman S,Adair C,O'Neill F,Goldsmith C,Webb H,Influence of selective decontamination of the digestive tract on microbial biofilm formation on endotracheal tubes from artificially ventilated patientsEur J Clin Microbiol Infect DisYear: 19931291710.1007/BF019970508462571
Feldman C,Kassel M,Cantrell J,Kaka S,Morar R,Goolam Mahomed A,Philips JI,The presence and sequence of endotracheal tube colonization in patients undergoing mechanical ventilationEur Respir JYear: 19991354655110.1183/09031936.99.1335469910232424
Costerton JW,Stewart PS,Greenberg EP,Bacterial biofilms: a common cause of persistent infectionsScienceYear: 19992841318132210.1126/science.284.5418.131810334980
Olson ME,Harmon BG,Kollef MH,Silver-coated endotracheal tubes associated with reduced bacterial burden in the lungs of mechanically ventilated dogsChestYear: 200212186387010.1378/chest.121.3.86311888974
Rumbak MJ,Newton M,Truncale T,Schwartz SW,Adams JW,Hazard PB,A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patientsCrit Care MedYear: 2004321689169410.1097/01.CCM.0000134835.05161.B615286545
Blot F,Similowski T,Trouillet JL,Chardon P,Korach JM,Costa MA,Journois D,Thiéry G,Fartoukh M,Pipien I,Bruder N,Orlikowski D,Tankere F,Durand-Zaleski I,Auboyer C,Nitenberg G,Holzapfel L,Tenaillon A,Chastre J,Laplanche A,Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patientsIntensive Care MedYear: 2008341779178710.1007/s00134-008-1195-418592210
Terragni PP,Antonelli M,Fumagalli R,Faggiano C,Berardino M,Pallavicini FB,Miletto A,Mangione S,Sinardi AU,Pastorelli M,Vivaldi N,Pasetto A,Della Rocca G,Urbino R,Filippini C,Pagano E,Evangelista A,Ciccone G,Mascia L,Ranieri VM,Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trialJAMAYear: 20103031483148910.1001/jama.2010.44720407057
Craven DE,Preventing ventilator-associated pneumonia in adults: sowing seeds of changeChestYear: 200613025126010.1378/chest.130.1.25116840410
Rello J,Lorente C,Bodí M,Diaz E,Ricart M,Kollef MH,Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia?: a survey based on the opinions of an international panel of intensivistsChestYear: 200212265666110.1378/chest.122.2.65612171847
Young PJ,Wyncoll DL,Continuous cuff pressure control and the prevention of ventilator-associated pneumoniaCrit Care MedYear: 20073524702471 author reply 2471. 17885409
Muscedere JG,Day A,Heyland DK,Mortality, attributable mortality, and clinical events as end points for clinical trials of ventilator-associated pneumonia and hospital-acquired pneumoniaClin Infect DisYear: 201051Suppl 1S12012520597661
Torres A,Aznar R,Gatell JM,Jimenez P,Gonzalez J,Ferrer A,Celis R,Rodriguez- Roisin R,Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patientsAm Rev Respir DisYear: 199014252352810.1164/ajrccm/142.3.5232202245
Rello J,Rue M,Jubert P,Muses G,Sonora R,Valles J,Niederman MS,Survival in patients with nosocomial pneumonia: impact of the severity of illness and the etiologic agentCrit Care MedYear: 1997251862186710.1097/00003246-199711000-000269366771
Nguile-Makao M,Zahar JR,Français A,Tabah A,Garrouste-Orgeas M,Allaouchiche B,Goldgran-Toledano D,Azoulay E,Adrie C,Jamali S,Clec'h C,Souweine B,Timsit JF,Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state modelsIntensive Care MedYear: 20103678178910.1007/s00134-010-1824-620232046
Kollef KE,Schramm GE,Wills AR,Reichley RM,Micek ST,Kollef MH,Predictors of 30-day mortality and hospital costs in patients with ventilator-associated pneumonia attributed to potentially antibiotic-resistant gram-negative bacteriaChestYear: 200813428128718682456
Heyland DK,Cook DJ,Griffith L,Keenan SP,Brun-Buisson C,The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials GroupAm J Respir Crit Care MedYear: 19991591249125610194173
Rello J,Ollendorf DA,Oster G,Vera-Llonch M,Bellm L,Redman R,Kollef MH,Epidemiology and outcomes of ventilator-associated pneumonia in a large US databaseChestYear: 20021222115212110.1378/chest.122.6.211512475855
Bercault N,Boulain T,Mortality rate attributable to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective case-control studyCrit Care MedYear: 2001292303230910.1097/00003246-200112000-0001211801831
Fagon JY,Chastre J,Hance AJ,Montravers P,Novara A,Gibert C,Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stayAm J MedYear: 19939428128810.1016/0002-9343(93)90060-38452152
Nseir S,Di Pompeo C,Soubrier S,Cavestri B,Jozefowicz E,Saulnier F,Durocher A,Impact of ventilator-associated pneumonia on outcome in patients with COPDChestYear: 20051281650165610.1378/chest.128.3.165016162771
Torres A,Aznar R,Gatell JM,Jiménez P,González J,Ferrer A,Celis R,Rodriguez- Roisin R,Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patientsAm Rev Respir DisYear: 199014252352810.1164/ajrccm/142.3.5232202245
Bauer TT,Ferrer R,Angrill J,Schultze-Werninghaus G,Torres A,Ventilator-associated pneumonia: incidence, risk factors, and microbiologySemin Respir InfectYear: 20001527227910.1053/srin.2000.2093811220409
Troché G,Moine P,Is the duration of mechanical ventilation predictable?ChestYear: 199711274575110.1378/chest.112.3.7459315810
Seneff MG,Zimmerman JE,Knaus WA,Wagner DP,Draper EA,Predicting the duration of mechanical ventilation. The importance of disease and patient characteristicsChestYear: 199611046947910.1378/chest.110.2.4698697853
Shorr AF,Zilberberg MD,Kollef M,Cost-effectiveness analysis of a silver-coated endotracheal tube to reduce the incidence of ventilator-associated pneumoniaInfect Control Hosp EpidemiolYear: 20093075976310.1086/59900519538095
Valles J,Blanch L,Respiratorias CE,Subglottic secretions and Sutton's law: a simple and effective approachCrit Care MedYear: 20083662362410.1097/01.CCM.0000299846.73263.3718216615
Tantipong H,Morkchareonpong C,Jaiyindee S,Thamlikitkul V,Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumoniaInfect Control Hosp EpidemiolYear: 20082913113610.1086/52643818179368


[Figure ID: F1]
Figure 1 

Diagram summarizing the pathogenic processes leading to ventilator-associated pneumonia (VAP; in black) and the preventative measures to combat each step (in red). Tooth brushing and chlorhexidine 2% washes help reduce oropharyngeal bacterial colonization [70]. The new generation of tracheal tubes forms the frontline barrier to reducing microaspiration by providing a better seal with the tracheal mucosa, allowing drainage of subglottic secretions and reducing colonisation of the lower respiratory tract.

[Figure ID: F2]
Figure 2 

Photograph of various bench tested tracheal tubes of different designs showing the internal channels created and the leak of liquid material past the cuff. Tube cuffs A and B are made from polyvinyl chloride, and cuffs C and D with thin polyurethane (C has an elongated cylindrical shape and D is a tapered cuff design). Tube E is the LoTrach™ ET tube. (Photograph courtesy of Dr Peter Young, Kings Lynn, UK.)

[Figure ID: F3]
Figure 3 

Endotracheal tube with subglottic suction port placed posteriorly and above the cuff for drainage of pooled secretion in the semi-recumbent position. Intermittent suction is applied to avoid ischaemic injury to the tracheal mucosa.

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