Prone position acute respiratory distress syndrome patients: less prone to ventilator associated pneumonia?

Excerpt

Acute respiratory distress syndrome (ARDS) and pneumonia are tightly entwined as pneumonia is both a frequent cause and a complication of ARDS. Compared to patients without ARDS, the incidence of ventilator associated pneumonia (VAP) appears to be higher in ARDS patients where reported VAP rates may be as high as 60 %, although these estimates vary and may be imprecise as a result of difficulties in diagnosing VAP. As ARDS patients represent a high-risk population for developing VAP, they might benefit the most from preventive measures. Many mechanical interventions have been proposed to prevent VAP. Among these, semirecumbent positioning, subglottic tracheal secretion aspiration, and continuous cuff pressure monitoring of the endotracheal tube have been tested in randomized controlled trials (RCTs). In a small but widely cited study, a dramatic decrease of VAP incidence was observed in patients assigned to 45° semirecumbent as compared to supine position [1]. However, no subsequent study could confirm these findings and maintaining a 45° semirecumbent position may be difficult to comply with in a real-life setting [2, 3]. Stronger evidence exists for subglottic secretion aspiration devices, with three RCTs showing VAP reduction amounting to 50, 42, and 64 %, respectively [4‐6]. Finally, continuous control of endotracheal tube cuff pressure is more controversial with two studies showing a decrease in VAP incidence [7, 8] and one study showing no effect [9]. None of these studies have specifically addressed these issues in ARDS patients. Evidence of efficacy of mechanical interventions in VAP prevention is presented in Table 1. …