• Airbag management
• Artificial airway management
• Attitudes
• Health knowledge
• Nurses
• Pathway analysis
• Practice

• Ventilator associated pneumonia
• care bundles
• measures
• non-pharmacologic
• pharmacologic
• prevention
• ventilator associated events

• Humans
• Pneumonia, Ventilator-Associated/prevention & control
• Practice Guidelines as Topic
• Patient Care Bundles/methods
• Respiration, Artificial/adverse effects
• Patient Care Team
• Health Care Costs
• Cross Infection/prevention & control

• costs and cost analysis
• critical care
• health expenditures
• intensive care units
• tracheostomy

• Humans
• Tracheostomy/methods
• Retrospective Studies
• Intensive Care Units
• Critical Care
• Costs and Cost Analysis

• Humans
• Pneumonia, Ventilator-Associated/epidemiology
• Pneumonia, Ventilator-Associated/prevention & control
• Pneumonia, Ventilator-Associated/drug therapy
• Chlorhexidine/therapeutic use
• Mouthwashes/therapeutic use
• Incidence
• Intensive Care Units

• COVID-19
• attributable mortality
• population attributable fraction
• ventilator-associated pneumonia

• COVID donor screening
• Deceased donor evaluation for SARS-CoV-2
• Donation after circulatory determination of death
• Donation after neurologic determination of death
• Intensive care management of donor
• Lung donor management
• Lung-protective ventilation
• Organ donation

• biofilm
• catheter
• medical devices
• microorganisms
• nosocomial infection
• treatment
• ventilation

• 952398 EU H2020-WIDESPREAD-05-2020
• VEGA 1/0537/19 Ministry of Education, Science, Research, and the Sport of the Slovak Republic

• artificial
• epidemiology
• equipment and supplies
• intratracheal
• intubation
• pneumonia
• primary prevention
• ventilation
• ventilator-associated

• Equipment Design
• Humans
• Intensive Care Units
• Intubation, Intratracheal/instrumentation
• Pneumonia, Ventilator-Associated/prevention & control
• Polyurethanes
• Polyvinyl Chloride
• Respiration, Artificial/methods

• critical care
• endotracheal tube
• knowledge
• manometer

Chlorhexidine oral care is widely used in critically and non-critically ill hospitalized patients to maintain oral health. We investigated the effect of chlorhexidine oral care on mortality in a general hospitalized population.

In this single-center, retrospective, hospital-wide, observational cohort study we included adult hospitalized patients (2012–2014). Mortality associated with chlorhexidine oral care was assessed by logistic regression analysis. A threshold cumulative dose of 300 mg served as a dichotomic proxy for chlorhexidine exposure. We adjusted for demographics, diagnostic category, and risk of mortality expressed in four categories (minor, moderate, major, and extreme).

The study cohort included 82,274 patients of which 11,133 (14%) received chlorhexidine oral care. Low-level exposure to chlorhexidine oral care (≤ 300 mg) was associated with increased risk of death [odds ratio (OR) 2.61; 95% confidence interval (CI) 2.32–2.92]. This association was stronger among patients with a lower risk of death: OR 5.50 (95% CI 4.51–6.71) with minor/moderate risk, OR 2.33 (95% CI 1.96–2.78) with a major risk, and a not significant OR 1.13 (95% CI 0.90–1.41) with an extreme risk of mortality. Similar observations were made for high-level exposure (> 300 mg). No harmful effect was observed in ventilated and non-ventilated ICU patients. Increased risk of death was observed in patients who did not receive mechanical ventilation and were not admitted to ICUs. The adjusted number of patients needed to be exposed to result in one additional fatality case was 47.1 (95% CI 45.2–49.1).

These data argue against the indiscriminate widespread use of chlorhexidine oral care in hospitalized patients, in the absence of proven benefit in specific populations.

The online version of this article (10.1007/s00134-018-5171-3) contains supplementary material, which is available to authorized users.

• Chlorhexidine oral care
• In-hospital mortality
• Risk of mortality

• Adolescent
• Adult
• Child
• Child, Preschool
• Cross-Over Studies
• Heating/instrumentation
• Humans
• Humidity
• Infant
• Infant, Newborn
• Pneumonia/etiology
• Randomized Controlled Trials as Topic
• Respiration, Artificial/adverse effects
• Steam
• Young Adult

• Artificial airway occlusion
• Heat and moisture exchangers
• Heated humidifiers
• Mortality
• Pneumonia

• care bundle
• evidence-based practice
• knowledge translation
• perioperative inadvertent hypothermia

• Cooperative Behavior
• Humans
• Hypothermia/therapy
• Patient Care Bundles
• Perioperative Care
• Postoperative Complications

• Intensive care unit
• Oral care
• Oral health
• Ventilator-associated pneumonia

A 52-year-old female presented to our clinic after accidentally ingesting a push-through pack (PTP). After determining that the PTP was present in the stomach, we successfully and safely removed it endoscopically by using a handmade endoscopic hood fashioned from a cut endotracheal tube. Foreign body ingestion is a common clinical problem, and most ingested foreign bodies pass spontaneously. However, the ingestion of sharp objects, such as PTPs, increases the risk of complications, and urgent endoscopy is recommended to remove such objects. Previous studies have reported the use of other devices, both commercial and handmade, for the safe endoscopic removal of foreign bodies. The novel design of our handmade hood for the removal of the PTP, which was fashioned from a cut endotracheal tube, was beneficial in terms of maintaining a wide visual field, patient safety and tolerance, and easy preparation compared to previously reported commercial and handmade devices. It may be a viable and safe device for the retrieval of PTPs and other sharp foreign bodies.

• Foreign body ingestion
• Endoscopic removal
• Push-through pack
• Sharp object
• Handmade

When conventional high-volume, low-pressure cuffs of endotracheal tubes (ETTs) are inflated, channel formation due to folds in the cuff wall can occur. These channels facilitate microaspiration of subglottic secretions, which is the main pathogenic mechanism leading to intubation-related pneumonia. Ultrathin polyurethane (PU)-cuffed ETTs are developed to minimize channel formation in the cuff wall and therefore the risk of microaspiration and respiratory infections.

We systematically reviewed the available literature for laboratory and clinical studies comparing fluid leakage or microaspiration and/or rates of respiratory infections between ETTs with polyvinyl chloride (PVC) cuffs and ETTs with PU cuffs.

The literature search revealed nine in vitro experiments, one in vivo (animal) experiment, and five clinical studies. Among the 9 in vitro studies, 10 types of PU-cuffed ETTs were compared with 17 types of PVC-cuffed tubes, accounting for 67 vs. 108 experiments with 36 PU-cuffed tubes and 42 PVC-cuffed tubes, respectively. Among the clinical studies, three randomized controlled trials (RCTs) were identified that involved 708 patients. In this review, we provide evidence that PU cuffs protect more efficiently than PVC cuffs against fluid leakage or microaspiration. All studies with leakage and/or microaspiration as the primary outcome demonstrated significantly less leakage (eight in vitro and two clinical studies) or at least a tendency toward more efficient sealing (one in vivo animal experiment). In particular, high-risk patients intubated for shorter periods may benefit from the more effective sealing capacity afforded by PU cuffs. For example, cardiac surgery patients experienced a lower risk of early postoperative pneumonia in one RCT. The evidence that PU-cuffed tubes prevent ventilator-associated pneumonia (VAP) is less robust, probably because microaspiration is postponed rather than eliminated. One RCT demonstrated no difference in VAP risk between patients intubated with either PU-cuffed or PVC-cuffed tubes, and one before-after trial demonstrated a favorable reduction in VAP rates following the introduction of PU-cuffed tubes.

Current evidence can support the use of PU-cuffed ETTs in high-risk surgical patients, while there is only very limited evidence that PU cuffs prevent pneumonia in patients ventilated for prolonged periods.

The online version of this article (doi:10.1186/s13054-016-1380-8) contains supplementary material, which is available to authorized users.

• Endotracheal tube
• Intubation
• Leakage
• Microaspiration
• Pneumonia
• Polyurethane cuff
• Prevention
• Respiratory infection
• Secretions
• Ventilator-associated pneumonia

• Critical care nursing
• Patient positioning
• Pressure ulcer
• Ventilator-associated pneumonia

• Humans
• Posture
• Pressure Ulcer/etiology
• Prospective Studies
• Respiration, Artificial

The management of tracheal tube cuff pressure in patients receiving mechanical ventilation is important for the prevention of ventilator-associated pneumonia. Currently, cuff pressure is intermittently monitored with a pressure gauge and adjusted when necessary in a routine practice. However, this method results in wide variations in pressure, and adequate management is difficult due to the spontaneous release of air from the cuff, which reduces cuff pressure. In order to continuously maintain a uniform cuff pressure, we developed a new automated cuff pressure controller and compared its properties with existing devices.

The effectiveness of the new device was assessed with a model trachea/lung and tracheal tube by measuring cuff pressure while on mechanical ventilation. An electrically powered automatic cuff controller or manual cuff pressure control was used for comparison purposes. The effectiveness of the new device was also examined in patients receiving mechanical ventilation by continuously measuring cuff pressure for a 24-h period.

Cuff pressure was uniformly maintained with the new device. Moreover, in the clinical setting, variation in pressure from the set pressure was minimal with both the new device and existing device, relative to the intermittent monitoring method. This suggests that, as with the existing device, uniform cuff pressure management is possible with the new device.

Our results demonstrate the ability of the new cuff pressure controller to manage cuff pressure without the need of a power source, highlighting its potential utility in clinical settings.

• Airway management
• Automated cuff pressure gauge
• Cuff pressure
• Mechanical ventilation
• Respiratory care
• Tracheal intubation

• Adult
• Aged
• Aged, 80 and over
• Anti-Bacterial Agents/therapeutic use
• Europe/epidemiology
• Female
• Humans
• Intensive Care Units
• Male
• Middle Aged
• Pneumonia, Ventilator-Associated/drug therapy
• Pneumonia, Ventilator-Associated/epidemiology
• Pneumonia, Ventilator-Associated/microbiology
• Pneumonia, Ventilator-Associated/mortality
• Prospective Studies
• Pseudomonas aeruginosa/isolation & purification
• Pulmonary Disease, Chronic Obstructive/complications
• Survival Analysis
• Treatment Outcome

Maintaining the cuff pressure of endotracheal tubes (ETTs) within 20–30 cmH₂O is a standard practice. The aim of the study was to evaluate the effectiveness of standard practice in maintaining cuff pressure within the target range.

This was a prospective observational study conducted in a tertiary-care intensive care unit, in which respiratory therapists (RTs) measured the cuff pressure 6 hourly by a handheld manometer. In this study, a research RT checked cuff pressure 2–4 h after the clinical RT measurement. Percentages of patients with cuff pressure levels above and below the target range were calculated. We identified predictors of low-cuff pressure.

We analyzed 2120 cuff-pressure measurements. The mean cuff pressure was 27 ± 2 cmH₂O by the clinical RT and 21 ± 5 cmH₂O by the research RT (p < 0.0001). The clinical RT documented that 98.0 % of cuff pressures were within the normal range. The research RT found the cuff pressures to be within the normal range in only 41.5 %, below the range in 53 % and above the range in 5.5 %. Low cuff pressure was found more common with lower ETT size (OR, 0.34 per 0.5 unit increase in ETT size; 95 % CI, 0.15–0.79) and with lower peak airway pressure (OR per one cm H₂O increment, 0.93; 95 % CI, 0.87–0.99) on multivariate analysis.

Cuff pressure is frequently not maintained within the target range with low-cuff pressure being very common approximately 3 h after routine measurements. Low cuff pressure was associated with lower ETT size and lower peak airway pressure. There is a need to redesign the process for maintaining cuff pressure within the target range.

• critical illness
• enteral nutrition
• gastric residual volume
• gastrointestinal motility
• gastrointestinal transit
• pneumonia
• respiratory aspiration
• ventilator associated pneumonia

Microaspiration of subglottic secretions through channels formed by folds in high volume-low pressure poly-vinyl chloride cuffs of endotracheal tubes is considered a significant pathogenic mechanism of ventilator-associated pneumonia (VAP). Therefore a series of prevention measures target the avoidance of microaspiration. However, although some of these can minimize microaspiration, benefits in terms of VAP prevention are not always obvious. Polyurethane-cuffed endotracheal tubes successfully reduce microaspiration but high quality data demonstrating VAP rate reduction are lacking. An analogous conclusion can be made regarding taper-shaped cuffs compared with classic barrel-shaped cuffs. More clinical data regarding these endotracheal tube designs are needed to demonstrate clinical value in addition to in vitro-based evidence. The clinical usefulness of endotracheal tubes developed for subglottic secretions drainage is established in multiple studies and confirmed by meta-analysis. Any change in cuff design will fail to prevent microaspiration if the cuff is insufficiently inflated. At least one well-designed trial demonstrated that continuous cuff pressure monitoring and control decrease the risk of VAP. Gel lubrication of the cuff prior to intubation temporarily hampers microaspiration through sludging the channels formed by folds in high volume-low pressure cuffs. As the beneficial effect of gel lubrication is temporarily, its potential to reduce VAP risk is probably nonsignificant. A minimum positive end-expiratory pressure of at least 5 cmH₂O can be recommended as it reduces the risk of microaspiration in vitro and in vivo. One randomized controlled study demonstrated a reduced risk of VAP in patients ventilated with PEEP (5–8 cmH₂O). Regarding head-of-bed elevation, it can be recommended to avoid supine positioning. Whether a 45° head-of-bed elevation is to be preferred above 25-30° head-of-bed elevation remains unproven. Finally, the routine monitoring of gastric residual volumes in mechanically ventilated patients receiving enteral nutrition cannot be recommended.

• Doença neuromuscular
• Mouthpiece
• Neuromuscular disease
• Noninvasive ventilation
• Open-circuit mouthpiece ventilation
• Parâmetros do ventilador
• Peça Bucal
• Ventilator settings
• Ventilação não invasiva
• Ventilação por peça bucal de circuito aberto

• cardiac surgery
• pathogen
• risk factor
• ventilator-associated pneumonia (VAP)

• Control de la seguridad
• Directrices
• Guidelines
• Haz de prevención
• Intensive care unit
• Mechanical ventilation
• Neumonía asociada a la ventilación mecánica
• Prevention bundle
• Safety assurance
• Unidad de cuidados intensivos
• Ventilación mecánica
• Ventilator-associated pneumonia

• Airway Extubation
• Critical Illness
• Humans
• Intensive Care Units
• Intubation, Intratracheal
• Time Factors
• Treatment Failure
• Ventilator Weaning/methods

• Antimicrobial treatment
• Health care–associated pneumonia
• Hospital-acquired pneumonia
• Nosocomial pneumonia
• Prevention
• Ventilator-associated complications
• Ventilator-associated pneumonia

• Adult
• Aged
• Anti-Infective Agents, Local/administration & dosage
• Chlorhexidine/administration & dosage
• Chlorhexidine/analogs & derivatives
• Critical Care
• Female
• Humans
• Incidence
• Intensive Care Units
• Intubation, Intratracheal
• Male
• Middle Aged
• Odds Ratio
• Pneumonia, Ventilator-Associated/microbiology
• Pneumonia, Ventilator-Associated/prevention & control
• Respiration, Artificial/adverse effects
• Toothbrushing/methods
• Trachea/microbiology

• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Anti-Bacterial Agents/therapeutic use
• Bacteria/classification
• Bacteria/drug effects
• Bacteria/isolation & purification
• Comorbidity
• Drug Resistance, Bacterial
• Female
• Hospital Mortality
• Humans
• Male
• Middle Aged
• Pneumonia, Ventilator-Associated/diagnosis
• Pneumonia, Ventilator-Associated/microbiology
• Pneumonia, Ventilator-Associated/mortality
• Pneumonia, Ventilator-Associated/pathology
• Prognosis
• Retrospective Studies
• Risk Factors
• Severity of Illness Index
• Taiwan
• Young Adult