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March 2019

Pneumonia prevention

Prevention of pneumonia: OHSU to test specialized breathing tubes

Pneumonia is the most common infection in sick patients in intensive care units. A new trial will test to see if a specialized tube can reduce the risk of pneumonia in emergency intubation situations. (Getty Images)

When taken to a hospital emergency room, few patients have the means to choose the type of breathing tube that will be inserted into their throat.

This is why OHSU is about to conduct a special type of clinical trial that recruits patients without their written consent. The United States Food and Drug Administration allows certain studies to be performed without written consent in emergency situations, provided that the patient has a high risk of dying without treatment, cannot speak because of their illness, no have no family available to speak on their behalf, and community members can opt out. (See the sidebar for unsubscribe instructions.)

The trial will compare two types of breathing tubes:

  • A standard tube currently in use in most emergency rooms and hospitals nationwide.

  • A specialized tube designed to reduce the risk of fluids leaking from the mouth and throat into the lungs, thereby reducing the risk of pneumonia.

The trial begins in April and is expected to last 36 months. It will enroll a total of 1,074 patients, half receiving the standard tube and the other half receiving the specialized tube. Known as a randomized controlled trial, the study will measure the benefits and risks resulting from specialized tubes compared to the standard tube.

The specialized tube has already been approved by the FDA as safe for clinical use. The new study will determine whether it is so effective that it should be adopted as the standard of care across the medical profession.

Myriam Treggiari (2014)

Miriam Treggiari, MD, Ph.D., MPH

“It could change clinical practice across the country and the world,” said Miriam Treggiari, MD, Ph.D., MPH, professor of anesthesiology and perioperative medicine at the OHSU School of Medicine who is leading the study.

The specialized tube includes a special balloon and an additional port that sucks fluids from the throat and mouth.

It is designed to reduce the risk of pneumonia, the most common infection in sick patients in intensive care units. Pneumonia can cause an increase in the time spent on a respirator and can increase the risk of death.

Participants will be followed for six months after placement of the breathing tube. While the tube is in place, researchers will watch for pneumonia and other possible complications. Six months after the breathing tube is removed, the study team will contact participants to determine if there are any lingering complications and their well-being.

The title of the study is “Randomized Trial of Endotracheal Tubes to Prevent Ventilator-Associated Pneumonia – Prevention Study 2” and is funded by the National Heart, Blood and Lung Institute of the National Institutes of Health with grants R61HL138650-01A1 and R33HL138650. Monitoring is provided by the FDA; the National Institute of the Heart, Blood and Lungs of the National Institutes of Health; and the OHSU Institutional Review Board and an independent Data Security Oversight Board.

Additional information:

If you wish to withdraw from the study, contact: 833-376-1027 or [email protected]

Details of the PreVent 2 study: apomocean.ohsu.edu


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Pneumonia prevention

Prevention of pneumonia is possible

Community-acquired pneumonia (CAP), an acute bacterial or viral alveolar infection of the lungs, manifests itself in a clinical spectrum.

CAP can be ambulatory pneumonia with anorexia, cough, dyspnea, and fever in otherwise healthy patients or so severe that it requires hospitalization (necrotizing or multilobar disease with septic shock). Pneumonia is the leading cause of death from infection in the United States and the eighth leading cause of death, along with influenza, and its incidence increases dramatically during influenza season (Figure1,3).1.2 In the United States, influenza and respiratory syncytial virus are common causes of viral pneumonia. Streptococcus pneumoniae is a common cause of bacterial pneumonia.3

RISK FACTORS

Anyone can get pneumonia from direct contact with respiratory secretions, but certain risk factors increase the likelihood (see Table 1.3). It should be noted that the influenza virus affects up to 20% of the general population each year. Pneumonia is one of the leading causes of death after influenza infection, particularly in the elderly and those with chronic illnesses or with co-morbidities. Influenza vaccination dramatically reduces influenza and pneumonia-related hospitalizations, with vaccine effectiveness ranging from 25 to 53%. In the elderly population, the efficacy of the vaccine is lower. For this reason, pharmacists should recommend one of the highly immunogenic influenza vaccines for the elderly.4.5

Many risk factors are well known, especially those associated with smoking and impaired lung function. Acute stroke is one that is underestimated. About 10% of people with acute stroke develop pneumonia.6 Pneumonia in this population is usually acquired in hospital and can be life threatening. Risk factors include chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, dysphagia, higher severity of strokes, male sex, advanced age, and pre-drug addiction. admission.6 Prophylaxis with antibiotics appears to reduce the incidence of post-stroke pneumonia, although study results are mixed.6.7 Pharmacists should also note an emerging factor: People who take or have recently used a benzodiazepine appear to be 1.25 times more likely to get pneumonia than those who do not. Although the reason for the association is unknown, the researchers suggest that relaxation of the esophageal sphincter and suppressing the immune system may increase the risk of pneumonia.8

A TRIAD OF PREVENTION TECHNIQUES

There are three approaches that can help prevent pneumonia, and pharmacy teams can help patients with all of them.

Stopping smoking is the most important action a patient can take to reduce the risk of CAP. Tobacco use impairs the immune system and lung function and often leads to COPD and increases the risk of pneumonia. Helping patients quit smoking is not easy, but with many different pharmacological interventions available, pharmacists can recommend suitable products effectively.9

Healthy living practices can also prevent infection. These include cleaning surfaces that people touch on a regular basis; cough or sneeze into a sleeve or tissue; manage ongoing medical conditions such as asthma, diabetes and heart disease; and wash your hands often and thoroughly. Also, removing mold from homes and workplaces and improving cleanliness and ventilation can help. Regular exercise also improves lung health.1.3

IMMUNIZATION

The third intervention, vaccination, is essential. Children under 2 years of age should be vaccinated against S pneumoniae and Haemophilus influenzae with a pneumococcal conjugate vaccine (PCV13) and against H influenzae type b. All healthy adults over 65 who have not received a dose should be vaccinated with PCV13 and then schedule pneumococcal polysaccharide vaccine at least 1 year later. The CDC also recommends the pneumococcal pneumonia vaccination for smokers and people aged 2 to 64 with chronic or immunocompromised conditions.ten This diet is especially important for patients with COPD. Pneumococcal vaccine has been shown to reduce the likelihood of CAP and COPD exacerbations. In addition, the annual flu shot reduces the likelihood of complications from the flu, including pneumonia.11.12

CONCLUSION

In 2016, the CDC reported 13.5 deaths per 100,000 Americans from influenza and pneumonia,13 the lowest rate ever recorded, against 53.7 per 100,000 before 1960 and 23.7 in 200013. But this number is still too high. Pharmacists can help reduce infections by recognizing pneumonia as a life-threatening disease, proactively fighting smoking, encouraging vaccination, and reminding patients that the flu and pneumonia are linked.

Jeannette Y. Wick, RPh, MBA, FASCP, is deputy director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy at Storrs.

THE REFERENCES

  • Waterer GW, Rello J, Wunderink RG. Management of community-acquired pneumonia in adults. Am J Respir Crit Care Med. 2011; 183 (2): 157-164. doi: 10.1164 / rccm.201002-0272CI.
  • CDC, National Center for Health Statistics. Main causes of death. CDC website. cdc.gov/nchs/fastats/leading-causes-of-death.htm. Updated March 17, 2017. Accessed January 3, 2019.
  • Pneumonia can be prevented – vaccines can help. CDC website. cdc.gov/pneumonia/prevention.html. Updated October 18, 2018. Accessed January 3, 2019.
  • Heo JY, Song JY, Noh JY, et al. Effects of influenza vaccination on pneumonia in the elderly. Hum Vaccine Immunother. 2018; 14 (3): 744-749. doi: 10.1080 / 21645515.2017.1405200.
  • Ballinger MN, Standiford TJ. Post-influenza bacterial pneumonia: the host’s defenses have gone bad. J Interferon Cytokine Res. 2010; 30 (9): 643-652. doi: 10.1089 / jir.2010.0049.
  • Badve MS, Zhou Z, van de Beek D, Anderson CS, Hackett ML. Frequency of post-stroke pneumonia: systematic review and meta-analysis of observational studies. Int J AVC. 2019; 4 (2): 125-136. doi: 10.1177 / 1747493018806196.
  • Badve MS, Zhou Z, Anderson CS, Hackett ML. Efficacy and safety of antibiotics for preventing pneumonia and improving outcomes after acute stroke: systematic review and meta-analysis. J Stroke Cerebrovasc Dis. 2018; 27 (11): 3137-3147. doi: 10.1016 / j.jstrokecerebrovasdis.2018.07.001.
  • Sun GQ, Zhang L, Zhang LN, Wu Z, Hu DF. Benzodiazepines or related drugs and risk of pneumonia: systematic review and meta-analysis [published online January 8, 2019]. Int J Geriatr Psychiatry. doi: 10.1002 / gps.5048.
  • San-Juan-Rodriguez A, Newman TV, Hernandez I, et al. Impact of preventive services provided by community pharmacists on clinical, use and economic outcomes: a general review. Previous med. 2018; 115: 145-155. doi: 10.1016 / j.ypmed.2018.08.029.
  • Vaccination schedules. CDC website. cdc.gov/vaccines/schedules/index.html. Updated February 5, 2019. Accessed February 14, 2019.
  • Kislaya I, Rodrigues AP, Sousa-Uva M, et al. Indirect effect of 7-valent and 13-valent pneumococcal conjugate vaccines on hospitalizations for pneumococcal pneumonia in the elderly. PLoS A. 2019; 14 (1): e0209428. doi: 10.1371 / journal. pone.0209428.
  • Song JY, Noh JY, Lee JS, et al. Efficacy of polysaccharide influenza and pneumococcal vaccines against influenza-related outcomes including pneumonia and acute exacerbation of cardiopulmonary disease: analysis by dominant viral subtype and vaccine pairing. PLoS A. 2018; 13 (12): e0207918. doi: 10.1371 / journal. pone.0207918.
  • Flu and pneumonia deaths in the United States from 1950 to 2016 (per 100,000 population). Statista website. statista.com/statistics/184574/deaths-by-influenza-and-pneumonia-in-the-us-since-1950/. Accessed February 14, 2019.


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