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To the Editors:

I am writing in regards to the article "Suctioning Techniques and Airway Management Practices: Pilot Study and Instrument Evaluation" (July 2002:363–368). As the author suggests, healthcare personnel may be able to decrease the occurrence of ventilator-associated pneumonia by implementing a variety of strategies, including meticulous oral care, thereby reducing the effects of aspiration of oral-pharyngeal secretions laden with bacteria. Of concern, however, is the misconception regarding the management of cuffs on endotracheal tubes and their perceived role in preventing aspiration.

Aspiration is generally considered to have taken place when material penetrates the larynx and enters the airway below the level of the true vocal folds, the last line of defense in the upper airway. The endotracheal tube, therefore, by its very placement, maintains the true vocal folds in an abducted position, allowing for constant microaspiration of oral-pharyngeal secretions that pool and stagnate above the cuff. While suctioning the oral cavity might reduce the amount of aspirated material, aspiration is inevitable and likely compounded by gastric reflux, a complication of supine positioning and nasogastric tube feedings.

There is a growing body of evidence suggesting that intubation, even as brief as 48 hours, may cause at least transient injury to the larynx with a subsequent reduction in the normal protective mechanism and an increased incidence of aspiration of oral-pharyngeal secretions and food and fluid once the patient is extubated and given an oral diet.

In addition to maintenance of oral and nasal hygiene and oral suctioning in the intubated patient, patients with a history of multiple intubations and/or prolonged intubation (more than 72 hours) should be considered as candidates for a bedside evaluation of swallowing function to help in identifying those patients who may have persistent aspiration, or "silent aspiration" (aspiration that does not elicit a laryngeal/cough response), following intubation. We have instituted such a policy in our facility and feel it has helped to reduce the amount of postextubation pneumonia.

Mary Spremulli, MA, CCC-SLP
Punta Gorda, Fla

References

1. Zoidas J. Preventing ventilator-associated pneumonia. J Resp Care Pract. April/May 2000:53–55.
2. Ajemian MS, Nirmul GB, Anderson MT, Zirlen DM, Kwasnik EM. Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management. Arch Surg. 2001;136:434–437.[Abstract/Free Full Text]

This Article Full Text (PDF) Respond to This Article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Spremulli, M. Search for Related Content PubMed PubMed Citation Articles by Spremulli, M.