Abstract
BackgroundMicroaspiration of gastric and oropharyngeal secretions is the main causative mechanism of ventilator-associated pneumonia (VAP). Transesophageal echocardiography (TEE) is a routine investigation tool in intensive care unit and could enhance microaspiration. This study aimed at evaluating the impact of TEE on microaspiration and VAP in intubated critically ill adult patients.MethodsIt is a four-center prospective observational study. Microaspiration biomarkers (pepsin and salivary amylase) concentrations were quantitatively measured on tracheal aspirates drawn before and after TEE. The primary endpoint was the percentage of patients with TEE-associated microaspiration, defined as: (1) ≥ 50% increase in biomarker concentration between pre-TEE and post-TEE samples, and (2) a significant post-TEE biomarker concentration (> 200 μg/L for pepsin and/or > 1685 IU/L for salivary amylase). Secondary endpoints included the development of VAP within three days after TEE and the evolution of tracheal cuff pressure throughout TEE.ResultsWe enrolled 100 patients (35 females), with a median age of 64 (53–72) years. Of the 74 patients analyzed for biomarkers, 17 (23%) got TEE-associated microaspiration. However, overall, pepsin and salivary amylase levels were not significantly different between before and after TEE, with wide interindividual variability. VAP occurred in 19 patients (19%) within 3 days following TEE. VAP patients had a larger tracheal tube size and endured more attempts of TEE probe introduction than their counterparts but showed similar aspiration biomarker concentrations. TEE induced an increase in tracheal cuff pressure, especially during insertion and removal of the probe.ConclusionsWe could not find any association between TEE-associated microaspiration and the development of VAP during the three days following TEE in intubated critically ill patients. However, our study cannot formally rule out a role for TEE because of the high rate of VAP observed after TEE and the limitations of our methods.
Highlights
Ventilator-associated pneumonia (VAP) is the most common acquired infection in critically ill patients under mechanical ventilation [1], often associated with significant morbidity [2, 3]
We evaluated the change in tracheal cuff pressure throughout Transesophageal echocardiography (TEE) procedure using one-way ANOVA and Dunnett multiple comparison test
The majority of eligible patients were excluded for logistical reasons or because of lack of sufficient tracheal secretions
Summary
Ventilator-associated pneumonia (VAP) is the most common acquired infection in critically ill patients under mechanical ventilation [1], often associated with significant morbidity [2, 3]. Pepsin comes from pepsinogen and is secreted by the chief cells in the stomach, and amylase is a digestive enzyme, secreted by the salivary glands and the pancreas Because they are not normally present in the respiratory tract, pepsin, and salivary amylase were proposed to diagnose microaspiration of gastric content and oropharyngeal secretions, respectively [9,10,11,12]. Their use in intubated critically ill patients is rapid, easy to perform in routine, cheap and only requires tracheal secretions. This study aimed at evaluating the impact of TEE on microaspiration and VAP in intubated critically ill adult patients
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