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Chapter 15 : Infections Associated with Endotracheal Intubation and Tracheostomy

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Abstract:

Bacterial infection is the most common cause of excess morbidity and mortality in patients who require endotracheal intubation or tracheostomy. The normal lung is sterile distal to the central carina, despite the daily inoculation of bacteria. Aspiration of liquids is prevented by reflex closure of the glottis following stimulation of receptors in the larynx and trachea and by the vigorous coughing that such stimulation evokes. Impairment of mucociliary function and mucus hypersecretion leads to pooling of secretions in the airways of intubated patients. Bacteria presented to the lung in a liquid bolus, such as contaminated upper-airway secretions, are cleared more slowly than bacteria presented as aerosols. Colonization by gram-negative bacilli (GNB) and other cextends to multiple contiguous sites including the oropharynx, endotracheal tube, tracheobronchial secretions, and stomach. Tracheobronchitis can be diagnosed when secretions become purulent, usually associated with an increased volume, viscosity, or both, with no new infiltrates visible on the chest radiograph. Tracheobronchitis frequently precedes nosocomial pneumonia in patients with endotracheal tubes or tracheostomies. Respiratory infection in patients with artificial airways is a dynamic process with virtually continuous inoculation of the airways with a changing bacterial flora, most of which is contained by lung defenses but with varying degrees of resultant inflammation. Sinusitis is clearly associated with an increased risk of nosocomial pneumonia, presumably due to the likelihood of aspiration of grossly infected material into the distal airways.

Citation: Dever L, Johanson W. 2000. Infections Associated with Endotracheal Intubation and Tracheostomy, p 307-324. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch15

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Figures

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Figure 1

Differences in the etiology of early (occurring within 72 h of admission) and late nosocomial pneumonia. The increased prevalence of gram-negalive organisms in the latter is a consequence of previous antimicrobial therapy and the changing colonization patterns associated with severe illness. Percentages are approximate.

Citation: Dever L, Johanson W. 2000. Infections Associated with Endotracheal Intubation and Tracheostomy, p 307-324. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch15
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Image of Figure 2
Figure 2

Axial CT scans of a 49-year-old man. (A) Normal paranasal sinuses were seen on the first day of endotracheal intubation. (B) Three days later, fluid (arrows) is seen in the frontal, ethmoid, and sphenoid sinuses bilaterally.

Citation: Dever L, Johanson W. 2000. Infections Associated with Endotracheal Intubation and Tracheostomy, p 307-324. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch15
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Tables

Generic image for table
Table 1

Histology and microbiology of 83 lungs at postmortem

Citation: Dever L, Johanson W. 2000. Infections Associated with Endotracheal Intubation and Tracheostomy, p 307-324. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch15
Generic image for table
Table 2

Empiric therapy of nosocomial pneumonia

Citation: Dever L, Johanson W. 2000. Infections Associated with Endotracheal Intubation and Tracheostomy, p 307-324. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch15
Generic image for table
Table 3

Prevention of infections in patients with artificial airways

Citation: Dever L, Johanson W. 2000. Infections Associated with Endotracheal Intubation and Tracheostomy, p 307-324. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch15

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