Endotracheal intubation: the role of sterility

BACKGROUND: There is a paucity of data regarding whether sterile handling of endotracheal tubes (ETTs) impacts the incidence and prevalence of pneumonia in the emergency, urgent, or elective clinical scenarios. Intensive care units employ infection control and reduction schemes to reduce pneumonia rates. METHODS: A MEDLINE search of the English-language literature for the last 30 years was performed using the keywords "endotracheal intubation," "intubation," "pneumonia," "sinusitis," "tracheobronchitis," "nosocomial infection," and "infection." Data were limited to those papers addressing the role of sterile handling or passage of ETTs, infection with antibiotic-resistant micro-organisms, antibiotic prophylaxis, and the role of virulence determinants in supporting invasive infection. Also, a convenience sample of a single author's patients requiring tracheal intubation was undertaken. Data were acquired on tube handling, success of insertion, and subsequent occurrence of pneumonia. RESULTS: Virtually no data exist on the impact of sterile ETT handling, but unsterile manipulation of the ETT prior to insertion is common (112 of 154 intubation events). Within the limited patient sample, no conclusions may be drawn regarding the impact of unsterile handling on pneumonia rates, although sinusitis after nasotracheal intubation clearly increases the incidence of pneumonia. Biofilm generation as a facilitator of bacterial colonization of artificial airway surfaces is a ubiquitous virulence determinant that is not ameliorated by antibiotic administration. CONCLUSIONS: Unsterile ETT handling and insertion techniques are not clearly associated with pneumonia induction, but physiologically sound approaches that retard biofilm production may decrease pneumonia rates.