Abstract
IntroductionLaboratory studies demonstrated that the lateral Trendelenburg position (LTP) is superior to the semirecumbent position (SRP) in the prevention of ventilator-associated pulmonary infections. We assessed whether the LTP could also prevent pulmonary colonization and infections caused by an endotracheal tube (ETT) biofilm.MethodsEighteen pigs were intubated with ETTs colonized by Pseudomonas aeruginosa biofilm. Pigs were positioned in LTP and randomized to be on mechanical ventilatin (MV) up to 24 hour, 48 hour, 48 hour with acute lung injury (ALI) by oleic acid and 72 hour. Bacteriologic and microscopy studies confirmed presence of biofilm within the ETT. Upon autopsy, samples from the proximal and distal airways were excised for P.aeruginosa quantification. Ventilator-associated tracheobronchitis (VAT) was confirmed by bronchial tissue culture ≥3 log colony forming units per gram (cfu/g). In pulmonary lobes with gross findings of pneumonia, ventilator-associated pneumonia (VAP) was confirmed by lung tissue culture ≥3 log cfu/g.ResultsP.aeruginosa colonized the internal lumen of 16 out of 18 ETTs (88.89%), and a mature biofilm was consistently present. P.aeruginosa colonization did not differ among groups, and was found in 23.6% of samples from the proximal airways, and in 7.1% from the distal bronchi (P = 0.001). Animals of the 24 hour group never developed respiratory infections, whereas 20%, 60% and 25% of the animals in group 48 hour, 48 hour-ALI and 72 hour developed P.aeruginosa VAT, respectively (P = 0.327). Nevertheless, VAP never developed.ConclusionsOur findings imply that during the course of invasive MV up to 72 hour, an ETT P.aeruginosa biofilm hastily colonizes the respiratory tract. Yet, the LTP compartmentalizes colonization and infection within the proximal airways and VAP never develops.
Highlights
Laboratory studies demonstrated that the lateral Trendelenburg position (LTP) is superior to the semirecumbent position (SRP) in the prevention of ventilator-associated pulmonary infections
Amid other Gram-negative pathogens, secretions were colonized by Escherichia coli in three endotracheal tube (ETT) (13.04%), Bordetella pertussis and Klebsiella pneumonia were found in one ETT each (4.35%)
P.aeruginosa was not found in only one ETT of group 24 h, which was instead colonized by Proteus vulgaris (7.85 log cfu/mL) and E.coli (7.85 log cfu/mL); whereas, in one ETT of group 48-acute lung injury (ALI) the internal surface was only colonized by Staphylococcus aureus and Bordetella bronchiseptica at a concentration of 6.41 and 4.40 log cfu/mL, respectively
Summary
Laboratory studies demonstrated that the lateral Trendelenburg position (LTP) is superior to the semirecumbent position (SRP) in the prevention of ventilator-associated pulmonary infections. Ill, intubated patients are commonly kept in the semirecumbent position to prevent the gastropulmonary route of endogenous colonization [1] and ventilator-associated pneumonia (VAP) [2]. Consistent data from laboratory studies [3,4,5] have suggested that the lateral Trendelenburg position (LTP) might be superior to the semirecumbent position in the prevention of VAP. The ETT is commonly made of polyvinylchloride and some bacterial species avidly adhere to polyvinylchloride and form biofilm [7,8]. More recently Wilson et al [15] found that mature biofilm (stage III/IV) was associated with the development of VAP
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