All physicians are obliged to obey the Hippocratic oath, which not only demands to cure disease but to prevent it. Setting aside the percentage of nonintubated patients with nosocomial pneumonia, this is largely a problem of endotracheal intubation needed for mechanical ventilation. If patients are intubated for management reasons, such as in the preoperative setting or in emergency medicine, it is unquestionable that there are no alternatives to the endotracheal route. Selective digestive decontamination (SDD) is always mentioned as a preventive measure once the patient has been intubated, and there is a recent publication3–
indicating an advantage in selected surgical patients. However, I am afraid that the SDD community has still not asked the correct questions. Since the systematic review by Nathens and Marshall,4–
it has to be accepted that SDD reduces mortality in surgical patients, but the central question remains whether this is due to the complete regimen of SDD—including topical and parenteral antibiotics—or to the parenteral application alone. At present, I think that other measures of prevention deserve more attention and that leads us back to the pathophysiology of nosocomial pneumonia. The risk increases with each day of mechanical ventilation and doctors have to ask whether they did not miss the most suitable time point to extubate the patient. Since the studies by Esteban and colleagues,5–6
we know that structured approaches result in early extubation, presumably reducing the incidence of nosocomial pneumonia in those patients. I dare to hypothesize that many ICUs have not adopted standardized criteria for entering a weaning trial or an extubation protocol, and we are therefore a long way from doing the best to prevent nosocomial pneumonia. Avoiding endotracheal intubation is crucial to the prevention of nosocomial pneumonia, and noninvasive mechanical ventilation is a proven tool in patients with acidotic exacerbation of COPD,7–
acute cardiogenic pulmonary edema,8–
and at least a potential for pulmonary infections.9–
In addition, noninvasive mechanical ventilation can also be successfully combined with a weaning protocol for selected patients, eg, patients with COPD or patients who failed multiple conventional weaning trials.11
Noninvasive mechanical ventilation has matured to a stage where institutional problems outweigh technical ones, and establishing noninvasive mechanical ventilation has become a challenge to ICU personnel rather than to the individual doctor. Of course, noninvasive mechanical ventilation will not and should not replace endotracheal intubation in all cases, but the summary of all preventive measures will lead definitely to a lower incidence of nosocomial pneumonia in our ICUs.