Chest
Volume 124, Issue 6, December 2003, Pages 2239-2243
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Clinical Investigations in Critical Care
Incidence, Etiology, and Outcome of Nosocomial Pneumonia in ICU Patients Requiring Percutaneous Tracheotomy for Mechanical Ventilation

https://doi.org/10.1378/chest.124.6.2239Get rights and content

Objective

To determine the epidemiology of pneumonia in patients with tracheotomy receiving short-term mechanical ventilation.

Design

Observational prospective study.

Setting

A 14-bed medical-surgical ICU.

Subjects

Ninety-nine critically ill acute patients requiring percutaneous dilatational tracheotomy for mechanical ventilation.

Interventions

Tracheal aspirate obtained 48 h before tracheotomy.

Measurements and main results

Eighteen patients (18.1%) acquired pneumonia (median of 7 days after tracheotomy). Pseudomonas aeruginosa was the most frequently identified pathogen, found in eight of the episodes (four not documented by prior tracheal colonization), followed by other Gram-negative bacilli. The development of ventilator-associated pneumonia (VAP) was not anticipated by any clinical variable. A positive tracheal aspirate (TA) culture result obtained before tracheotomy was associated with a risk of acquiring pneumonia of 19.7%, whereas sterile TA cultures were associated with a risk of 14.3% (p > 0.20). VAP prolonged ICU stay or the ventilation period for a median of 19 days and 15 days, respectively. Overall mortality was 34.3%, but the presence of VAP did not increase the mortality rate.

Conclusions

Percutaneous tracheotomy in patients receiving short-term mechanical ventilation predisposes to pneumonia. Pneumonia was associated with prolonged ventilation and ICU stay, but was not associated with increased mortality. Pseudomonas is a common pathogen after tracheotomy, and this observation should be considered in selecting an antibiotic regimen, because TA obtained prior to the tracheotomy often failed to identify this pathogen.

Section snippets

Study Population

The study was conducted in a 14-bed medical-surgical ICU at a teaching hospital from January 2000 until June 2002. All patients who required tracheotomy during the ICU stay were eligible for study. Patients were excluded if the tracheotomy was performed prior to ICU admission. Surgical tracheotomies were performed by an otorhinolaryngologic surgical specialist in the operating room, and these patients were also excluded. Percutaneous tracheotomies were performed by the ICU staff (C.B., M.B.,

Results

A total of 796 consecutive patients received intubation and mechanical ventilation over the study period, representing 6,833 ventilation-days. One hundred ten of these patients (13.8%) underwent tracheotomies. Eleven patients underwent a surgical tracheotomy in the operating room due to existence of contraindications for percutaneous tracheotomy: morbid obesity (n = 4), unstable cervical fracture n = 3), uncertainty in identifying the anatomic landmarks (n = 3), and emergency surgical airway

Discussion

This study investigated the epidemiology of pneumonia and other infectious complications in patients receiving short-term mechanical ventilation requiring tracheotomy in the ICU. In contrast with intubated patients, this subset of patients has been investigated rarely in the literature.10 A unique aspect of this study is that all patients underwent percutaneous tracheotomy. Our findings suggest that the risk of transient bacteremia or wound infections is marginal. The risk of pneumonia was

ACKNOWLEDGMENT

We wish to thank Marta Roque for statistical support, Carmen Ardanuy for microbiologic support, and Michael Maudsley for editing the manuscript.

References (16)

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Supported in part with grants from Comissio Interdepartmental Recerca i Technologica (SGR2001-414) and Distincio a la Promocio de la Recerca Universitaria (Dr. Rello).

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