Indian Journal of Critical Care Medicine
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LETTER TO THE EDITOR
Year : 2010  |  Volume : 14  |  Issue : 4  |  Page : 220

More about chest physiotherapy and ventilator-associated pneumonia prevention


Guys' and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, United Kingdom

Date of Web Publication22-Jan-2011

Correspondence Address:
George Ntoumenopoulos
Guys' and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London
United Kingdom
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DOI: 10.4103/0972-5229.76090

PMID: 21572757

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How to cite this article:
Ntoumenopoulos G. More about chest physiotherapy and ventilator-associated pneumonia prevention. Indian J Crit Care Med 2010;14:220

How to cite this URL:
Ntoumenopoulos G. More about chest physiotherapy and ventilator-associated pneumonia prevention. Indian J Crit Care Med [serial online] 2010 [cited 2014 Oct 25];14:220. Available from: http://www.ijccm.org/text.asp?2010/14/4/220/76090


Dear Editor,

I read with interest the recent publication by Pattanshetty and Gaude on the role of chest physiotherapy for the prevention of ventilator-associated pneumonia (VAP). [1] This randomized controlled trial is an important addition to the evidence base for non-pharmacological measures to reduce VAP and deserves further comment.

Pattanshetty and Gaude report on the clinical evolution of the clinical pulmonary infection score (CPIS) after intubation and mechanical ventilation, as a surrogate measure of VAP. The authors, however, did not formally report an actual VAP rate (CPIS > 6) for the study. The CPIS has limited sensitivity and specificity and hence may not be the most suitable measure to estimate VAP. [2] Chest physiotherapy for VAP prevention and/or treatment is supported by the evidence that intubation and mechanical ventilation cause airway secretion retention and result in VAP. [3] However, the evidence base for chest physiotherapy for the prevention of VAP is inconsistent. [4] VAP prevention strategies focus on minimizing risk from the aero-digestive tract colonization and oropharyngeal aspiration recommending 45° head-up positioning and chest physiotherapy is not recommended. [5] However, head-down positioning (common component of chest physiotherapy) can facilitate airway secretion clearance and assist to prevent VAP, whereas controversially head-up positioning may impair airway mucus clearance and cause VAP. [6] This supports the role of chest physiotherapy for VAP prevention but requires further clinical confirmation.

The authors should have investigated the impact of other known risk factors associated with VAP such as chronic obstructive pulmonary disease chronic obstructive pulmonary disease (COPD), airway intubation, mechanical ventilation time, intracranial monitoring, airway re-intubation, use of positive end expiratory pressure (PEEP), steroid use, tracheostomy, reduced conscious state and admission acute physiology and chronic health evaluation (APACHE) II score. [7] Considering that there were differences in mortality rates between the two groups, [1] this indicates there may have been group differences (e.g. APACHE II) that have not been accounted for. To improve trial transparency, the authors also should have used the Consort Style of reporting. There are referencing inaccuracies in the body of the text (Jessica et al. should be Choi et al.). The authors also neglected to report on the microbiological results of the sputum samples, which would have provided a more valid and specific diagnosis of VAP. [1]

 
 » References Top

1.Pattanshetty RB, Gaude GS. Effect of multimodality chest physiotherapy in prevention of ventilator-associated pneumonia. A randomized clinical trial. Indian J Crit Care Med 2010;14:70-6.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Zilberberg MD, Shorr AF. Ventilator-associated pneumonia: the clinical pulmonary infection score as a surrogate for diagnostics and outcome. Clin Infect Dis 2010;51:131-5.  Back to cited text no. 2
    
3.Konrad F, Schreiber T, Brecht-Kraus D, Georgieff M. Mucociliary transport in ICU patients. Chest 1994;105:237-41.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Templeton M, Palazzo MG. Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours. Intensive Care Med 2007;33:1938-45.  Back to cited text no. 4
    
5.Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D. VAP Guidelines Committee and the Canadian Critical Care Trials Group. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia prevention. J Crit Care 2008;23:126-37.  Back to cited text no. 5
    
6.Bassi G, Zanella A, Cressoni M, Stylianou M, Kolobow T. Following tracheal intubation, mucus flow is reversed in the semi-recumbent position: possible role in the pathogenesis of ventilator-associated pneumonia. Crit Care Med 2008;36:518-25.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Pawar M, Mehta Y, Khurana P, Chaudhary A, Kulkarni V, Trehan N. Ventilator-associated pneumonia: Incidence, risk factors, outcome, and microbiology. J Cardiothorac Vasc Anesth 2003;17:22-8.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  



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Pattanshetty, R.B., Gaude, G.S.
Indian Journal of Critical Care Medicine. 2010; 14(4): 221
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