How Can the Nurse Best Minimize a Patientã¢â‚¬â„¢s Risk for Infection During Tracheostomy Care?

Preventing Infection in Individuals with Tracheostomy

Maintaining a high level of infection control is the responsibility of all health care staff working with whatsoever patient, particularly with individuals with tracheostomy and mechanical ventilation in order to ensure the safety of the patient, visitors and staff.  Infection may exist bacterial (gram negative organisms,Streptococcus pneumoniae, Haemophilus influenzae, Staphylococci and b Haemolytic Streptococcus Group A) or viral (respiratory synctial virus, parainfluenza) in nature.

Infection rates may be reduced with standard infection control procedures (manus hygiene, personal protective equipment), decontamination of respiratory equipment, reducing the potential for aspiration, reducing sedation needs, improving secretion management, and adequate tracheostomy cleaning and care.  Weaning and decannulation volition have the greatest impact on reducing the hazard of infection.

Educate wellness care workers nigh infection command procedures and prevention methods to amend competency and adherence to hospital infection command procedures.  Educate workers according to the worker'due south level of responsibility in the wellness intendance setting and involve workers in the implementation of intervention to forestall infections by using performance improvement tools and techniques.

Common Pathogens

The infections about frequently associated with tracheostomy are either tracheobronchitis or mainly pneumonia, with upward to sixty% of hospitalized patients developing pneumonia (Ahmed, QA, 2001). Diagnosis of an infection is sometimes difficult because patients with tracheostomy are often colonized with potentially pathogenic leaner. The diagnosis is frequently made on clinical features such as cough, purulent secretion, systemic signs of infection, impairments in gas commutation and the presence of an infiltrate on breast x-ray, should besides be checked.

Gram-negative organisms are responsible for 50% of deep infections in patients with tracheostomies. Streptococcus pneumoniae, Haemophilus influenzae, Staphylococci  and b Haemolytic Streptococcus Group A are besides common causes of bacterial infection in the patient.

Risk Factors for Infection in Patients with Tracheostomy

In that location is a high susceptibility for infection in patients with tracheostomy due to the loss of function of the upper airway.  With an inflated gage, there is a loss of airflow through the upper airway.  Some of the functions of the upper airway include status of inspired air to torso temperature and 100% relative humidity.  Tracheostomy can lead to pathological changes of the lower airways, including damage to the ciliated tracheal mucosa, thickening of airway secretions, and the loss of mucociliary transport.  Repeated cleaning and suctioning of the lower airway/the trachea is necessary, which results in significant patient discomfort and increases the take a chance of lower respiratory tract infection and airway obstruction.  Other complications of the tracheostomy that may increase the risk of infection is that the patient may have poor secretion management and an increased gamble of aspiration.

Fagon et al. suggested that the incidence of VAP increases by 1% per day of invasive mechanical ventilation.  Take a chance factors associated with bacterial colonization include residing in a medical care home and the presence of a cuff (Lepainteur, One thousand, 2019).  The presence of a cuff has too been associated with increased respiratory infections (Hernandez, 2012).Respiratory secretions pool around the cuff of the tracheostomy tube and will gradually leak past the gage downwards into the lungs. Gastric contents, heavily colonised with Gram-negative organisms may also be aspirated into the lungs.  The cuff also reduces the ability for the patient to finer clear secretions to a higher place the gage.

Other general risks include poor overall health and oral hygiene.

• Patients in healthcare who have underlying medical conditions such as diabetes, cancer, and organ transplantation are at increased risk for infection considering oftentimes these illnesses subtract the immune system'due south ability to fight infection.
• Certain medications used to treat medical conditions, such as antibiotics, steroids, and certain cancer fighting medications increase the risk of some types of infections.
• Lifesaving medical treatments and procedures used in healthcare such equally urinary catheters, tubes, and surgery increase the risk of infection by providing additional ways that germs can enter the body.  The tracheostomy tube may exist a conduit for germs through the open up tracheostomy tube.
• Poor oral care is associated with infection from aspiration of bacteria in the oral cavity.

Ventilator Associated Pneumonia

The definition of ventilator associated pneumonia has been debated in the literature. A detail difficulty with many commonly-used VAP definitions, including the NHSN PNEU definitions (revised in 2002), is that they require radiographic findings of pneumonia. Evidence suggests that chest radiograph findings practise not accurately identify VAP. The subjectivity and variability inherent in chest radiograph technique, interpretation, and reporting make chest imaging ill-suited for inclusion in a definition algorithm to exist used for the potential purposes of public reporting, inter-facility comparisons, and pay-for-reporting and pay-for-functioning programs.

In 2011, the Centers for Disease control established a new approach to surveillance of Ventilator Associated Events (VAE).  There are three definition tiers within the VAE algorithm:

1. Ventilator-Associated Condition (VAC)
2. Infection-related Ventilator-Associated Complexity (IVAC)
3. Possible VAP (PVAP).

Tismit and colleagues accept summarized the definitions equally follows:

"VAC is the first stride of VAE surveillance, with the aim of identifying any complication occurring in mechanically ventilated patients, regardless of the origin or mechanism. To come across the definition of VAC, a mechanically ventilated patient must have at to the lowest degree ii days of stability or improvement of respiratory parameters—such as a stable or decreasing daily minimum positive cease-expiratory pressure level (PEEP) or fraction of inspired oxygen (FiO_ii)—followed by at least ii days of worsened oxygenation (diagnosed by an increase of the daily minimum PEEP (at least 3 cm H₂O) or FiO₂(at least 20%)). The concept of IVAC aims to place the subgroup of VACs that are potentially related to infection. A VAC associated with an abnormal white claret cell count or a modified temperature becomes an IVAC if the initiation of a new antimicrobial agent is maintained for at least four days. With evidence of purulent respiratory secretions or positive results of microbiological tests performed on respiratory tract specimens or both, an IVAC becomes a possible VAP."

Risk Factors for Ventilator Associated Pneumonia

Risk factors for VAP (Nseir, 2007; Koenig, S & Truwit, J, 2006):

Host related risk factors:

• Neurological injury
• Corticosteriod Use
• Gastric PH-modifying agents
• Medical history and underlying illness
• Male gender
• Extreme historic period
• Prior central nervous organisation disorder
• Immunocompromised
• Acute underlying diseases
• Emergent surgery
• Neurosurgery, theracic surgery and cardiac surgery
• Burns
• Re-intervention
• Acute severity factors
• Organ system failure alphabetize of at least iii
• Acute renal failure
• Acute respiratory distress syndrome
• ECMO, intra-aortic support
• Ulcer disease

Intervention related hazard factors:

• Duration of intubation and mechanical ventilation
• Reintubation
• Supine positioning during enteral feedings
• Enteral diet
• Antibody employ
•  Poor infection control conditions
• Contaminated respiratory equipment, medications, or water
• Absence of subglottic secretion drainage
•  Frequent vent circuit changes

Standard Infection Control Methods

Infection control prevents the spread of infection.  Standard Precautions apply to 1) blood; ii) all torso fluids, secretions, and excretions,except sweat, regardless of whether or not they comprise visible claret; 3) non-intact skin; and 4) mucous membranes.  Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.Standard precautions includes the utilise of: hand hygiene and advisable personal protective equipment.

Paw Hygiene

Microbes are caused on the skin from directly contact with people, surfaces and the environment and is the mode of spread for the majority of health intendance associated infections.  Hand hygiene reduces the risk of transmission of infection from patient to patient as well as to the healthcare worker.  It has also been shown to reduce morbidity, mortality and costs associated with health care associated infections (CDC, 2002).  Hand hygiene is a simple, all the same effective mode to preclude the spread of affliction.  Contaminated easily or equipment can pose a threat to patients with tracheostomy, who are specifically susceptible at tracheostomy wound sites, during tracheostomy intendance or suctioning.

If hands are visibly dirty or if the patient has a C. difficile infection, the hands should exist washed with soap and water.  Hands should be washed thoroughly, at least fifteen seconds, making certain all parts of the hands are clean. The pollex, fingertips and between the fingers are the most often missed areas.  If the hands are non visibly dirty, alcohol based hand sanitizer is the preferred method of cleaning.  Compared to lather and water, alcohol based hand sanitizer is moreeffective at killing potentially mortiferous germs on hands, r equires less time, i due south more accessible, produces reduced bacterial counts on easily, and i mproves skin condition with less irritation and dryness (CDC, 2019).  Hand hygiene should be performed whether or non gloves are worn.

Withal, despite the testify that hand hygiene prevents the spread of infection, healthcare worker adherence to hand hygiene protocols has been poor.

CDC Guideline for Hand Hygiene

Use of Personal Protective Equipment

Personal protective equipment (PPE) such as gowns, gloves, masks, and goggles protect the patient from infection from other patients and also assistance to protect the healthcare worker.  The use of gloves is a standard precaution for all patient care.  Glove utilize is not an alternative for hand washing.  Hands should exist done earlier placing gloves and later on removal.

The type of protective equipment used should exist ascertained by risk assessment of known or suspected infections, the procedure to be performed and the anticipated degree of contact with blood or trunk fluids.  When involvement with respiratory secretions from a patient is anticipated, wear a gown and change it afterwards soiling occurs and before providing care to another patient.  During suctioning with an open suction catheter, consider use of a gown and protective eye wear in addition to gloves, particularly if the patient has an infection or copious secretions.

Transmission-Based Precautions (i.eastward., Airborne Precautions, Droplet Precautions, and Contact Precautions), are recommended to provide additional precautions across Standard Precautions to interrupt transmission of pathogens in hospitals.

• • Airborne Precautions used for infections spread in small particles in the air such every bit craven pox.
  • Droplet Precautions  used for infections spread in large droplets by coughing, talking, or sneezing such equally flu.
  • Contact Precautions  used for infections spread by peel to pare contact or contact with other surfaces such as herpes simplex virus.

Tracheostomy Specific Concerns for Infection

Tracheostomy Stoma Infection

The incidence of tracheostomy stoma infection varies from institutions. Stoma infections can occur following the tracheotomy process, merely may be reduced following percutaneous dilational tracheotomy procedures (PDT).  Post-obit surgical tracheotomy, rates vary betwixt 0-63%, while PDT rates have been between 0-10% (Durbin, 2005).  The site should be inspected daily for signs of infection.  Signs of tracheostomy stoma infection include erythematous change, swelling around wound, purulent belch from wound and discharge culture with bacterial growth.  The patient may also complain of pain at the tracheotomy site.

It is important to keep the stoma site dry and free of secretions every bit moisture tin predispose the patient to infection and pare breakup.  See Stoma Treat more information.

Tracheostomy Suctioning

There are open or closed suction catheters.  No recommendation tin can be made for the preferential use of either the multi-use closed-organisation suction catheter or the single-apply open-system suction catheter for prevention of pneumonia (CDC, 2003).  If the open-system suction is employed, use a sterile, unmarried-utilise catheter (CDC, 2003).  During apply of an open suction catheter, if the healthcare workers hands are contaminated and touch on the suction catheter, bacteria tin can easily be transmitted.  With an open suction catheter, secretions tin can easily exist expelled out the tracheostomy tube and contaminate the wellness care worker and the surround.  Southuctioning therefore will require gloves, possibly a protective apron and staff may consider a mask and heart protection necessary if the patient is suffering from an infectious condition, or in that location are copious secretions which may result in splashing or droplets spray.

Closed suctioning is recommended for patients with mechanical ventilation to prevent disconnection from the ventilator which can upshot in atelectasis.  Disconnections also may allow for foreign objects including leaner to contaminate within the tracheostomy tube.  Closed suctioning tin reduce the healthcare workers exposure to sputum.  The CDC (2003) does non accept a recommendation nearly the frequency of routinely irresolute the in-line suction catheter of a closed-suction arrangement in use on ane patient.

For suctioning procedures and more information, please see Tracheostomy Suctioning.

Suctioning of the oral cavity with a suction catheter or Yankaeur suction can be included in a comprehensive oral hygiene program to reduce or prevent oral colonization of leaner.

Tracheostomy Tube Intendance

Proper care including cleaning of the inner cannula and routine tracheostomy tube changes are important in preventing infections.  Hand hygiene should be performed before and afterwards tracheostomy tube care.  When changing a tracheostomy tube, wear a gown, use aseptic technique, and supplant the tube with one that has undergone sterilization or high-level disinfection.

Humidification and Nebuilizer Treatments

Individuals with tracheostomy have a loss of airflow through the upper airway, and therefore are unable to humidify and filter the lower airway sufficiently.  Ciliated epithelial cells are the basis of mucociliary ship in the upper and lower airway. Their primary chore is the elimination of dust and inhaled particles past transporting droppings in a layer of fungus with a fast and synchronous ciliary beat frequency (CBF).

Artificial humidification such as HMEs and heated humidification are a standard of care for individuals with tracheostomy to compensate.In a prospective comparison of heated humidification to HME apply, the patients using heated humidification required forty% less suctioning which may have been due to an increased number of ciliated epithelial cells in that group following heated humidification (Birk, R., 2013).

Humidifiers and nebulizer treatment are particularly vulnerable to colonization past Gram negative bacteria. Single use nebulizers may reduce this run a risk.  If multidose medication vials are used, follow manufacturers' instructions for handling, storing, and dispensing the medications.  Betwixt treatments on the same patient, rinse the nebulizer out with sterile h2o and dry out thoroughly after each use.  The fluid should exist dispensed aseptically (CDC, 2003).

Breathing circuits with humidifiers:

1. Breathing circuits should non be changed routinely.  But change the circuit when visibly dingy or. malfunctioning
2. Periodically bleed and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to permit condensate to drain toward the patient.
3. U se sterile (non distilled, nonsterile) water to fill bubbling humidifiers.
4. No recommendation can be fabricated for the preferential use of a closed, continuous-feed humification system (CDC, 2004).

Ventilator breathing circuits with HMES:

1. No recommendation can exist made for the preferential employ of either HMEs or heated humidifiers to preclude pneumonia in patients receiving mechanically assisted ventilation.
2. Do non routinely change an HME more oft than every 48 hours.
3. Do not routine alter (in the absence of gross contamination or malfunction) a breathing circuit that is in utilize past a patient more frequently than every 48 hours (CDC, 2003).  Changing the ventilator circuit only when clinically indicated such as visible soiling or when faulty, does not increase the incidence of VAP and would effect in significant cost savings compared to routine irresolute of circuit (Intensive Care Society, 2013).

Sedation

Sedation of endotracheally intubated patients is universal to ensure patient condolement. Continuous sedation can lead to accumulation of sedatives and over-sedation, and is associated with increased duration of mechanical ventilationSince intubation and mechanical ventilation predisposes patients to VAP, reducing the duration of mechanical ventilation should reduce that time at risk for developing VAP. Two strategies that take been used to reduce the duration of mechanical ventilation are daily sedation suspension (DSI) and daily spontaneous breathing trials (SBT). According to the Intensive Care Order, there is sufficient evidence to back up the employ of daily sedation intermission to prevent over-sedation and liberation from mechanical ventilation through daily spontaneous breathing trials (Hellyer, et al, 2016).

Long periods of sedation can impair pharyngeal function, airway protection and coordination of breathing and swallowing (Hardemark Cedbard, A, 2015).  Sedation also causes prolongation of the timing for initiation of the swallowing reflex and a decrease in the number of swallows elicited (Nishino et al., 1987).  Muscle atrophy can occur from limited use of the muscles for swallowing.  Reduction in sedation may as well let for early on intervention of swallowing therapy to reduce muscle disuse and aspiration risk.

Precautions for Prevention of Aspiration

The Center for Affliction Control, in the Guidenline for Prevention of Healthcare Associated Pneumonia, the following is recommended:

As shortly as the clinical indications for their use are resolved, remove devices such as endotracheal, tracheostomy, and/or enteral (i.e., oro- or nasogastric or jejunal) tubes from patients

Having a tracheostomy tube is a risk factor for aspiration with the potential to lead to the development of pneumonia.  Food, liquid, and secretions are able to laissez passer around the tracheostomy tube cuff and into the lower airways.  Patients with an inflated cuff are at high risk of aspiration.  Run into the Swallowing Management of Individuals with Tracheostomy page for more than information almost preventing aspiration and dysphagia management.

In a randomized study, those with the gage deflated weaned quicker and had significantly less respiratory infections than those in the cuff inflated grouping (Hernandez et al, 2012).  Prior to deflating the cuff of the tracheostomy (or endotracheal tube), suctioning should be performed to reduce the take chances of aspirated secretions from inbound the lower airways.

Decannulationis recommended  as soon as feasible, if it tin can be achieved safely.Cuff deflationis an important step in the decannulation process.

Prevention of Aspiration with Endotracheal Tube

If feasible and non medically contraindicated, the use of non-invasive ventilation to reduce the need of endotracheal intubation or for weaning purposes can reduce aspiration pneumonia risks.  Unless contraindicated, orotracheal intubation rather than nasotracheal intubation also reduces pneumonia rates.  The apply of an endotracheal tube with a dorsal lumen above the endotracheal cuff to permit drainage (by continuous or frequent intermittent suctioning) of tracheal secretions that accumulate in the patient'due south subglottic area may also reduce VAP.  Prior to gage deflation for extubation, utilize of a subglottic suctioning may reduce aspirated secretions from entering the lungs.   Also avoiding echo endotracheal intubation in patient who have received mechanical ventilation (CDC, 2003).  Repeated intubations increment the likelihood of impairment to the vocal fold and surrounding mucosa, which increases aspiration risk.

One time intubation has occurred the focus of reducing risk of VAP should be at reducing colonization and aspiration (Koenig, S & Truwit, J 2006) to reduce the risk of pneumonia.  Fagon et al. suggested that the incidence of VAP increases by 1% per twenty-four hours of invasive mechanical ventilation.  Intubated patients may exist more prone to develop VAP equally compared to those with a tracheostomy considering the ETT keeps the trachea and the oropharynx in communication, acting as a span for bacteria to move toward the dependent airways.

VAP rates are likely high in individuals with both endotracheal tubes and tracheostomy tubes due to medical fragility also equally the interference of normal physiological mechanisms to clear the airway of bacterial contaminants.  With an inflated cuff, the individual is unable to produce an constructive coughing reflex.  Tracheostomy allows for better oral hygiene too as the possibility of gage deflation to begin re-establishing airflow and utilise of the vocal folds.  Tracheostomy may too permit for faster weaning from mechanical ventilation.  However, VAP has not been shown to exist dissimilar in early on versus late tracheostomy (Terragni, 2011).

Prevention of Aspiration with Enteral Feeding Tube

Patients with tracheostomy and/or mechanical ventilation are at high risk of aspiration, even if an enteral feeding tube is in place.  Enteral feeding includes nasogastric, gastrostomy, and jejunal tubes.  When a nasogastric tube is initially placed, verify appropriate placement with a chest x-ray.  Colorimetric capnography is another valid method for verifying NG tube positioning in mechanically ventilated patients.

Aspiration can occur from reflux or vomitus of enteral feeding.To prevent aspiration,  drag the head of the bed at an angle of 30-45 degrees, unless contraindicated by medical conditions(s).  No recommendation for preferential utilize of small diameter feedings, continuous versus intermittent or placing feeding tubes distal to the pylorus (CDC, 2004).

In terms of nasogastric tubes, the presence of a NGT has been associated with difficulty swallowing.  In a 15 elderly individuals with normal swallowing, NGT increased airway penetration-aspiration (fine bore NGT with serial liquid swallows and puree)  (ii) increased pharyngeal rest in the pyriform sinus (fine diameter NGT with puree) and in the valleculae (both fine and wide bore NGT with soft solids) and (iii) an increase in pharyngeal transit duration regardless of consistency with longest swallowing durations with the widest tube (Pryor, 2015).  Similarly, in young normals, the presence of a wide-diameter nasogastric tube acquired significant elapsing changes in several swallowing measures, namely duration of stage transition, duration of pharyngeal response, duration of pharyngeal transit, and duration of upper esophageal sphincter opening. Similar trends were seen for the fine-bore tube (Huggins, PS, 1999).

Prevention of oropharyngeal colonization

The literature shows a strong correlation between oropharyngeal bacterial colonization and presence of causative bacteria of VAP.  Oral hygiene care is critical in reducing oropharyngeal colonization of bacteria and reducing ventilator associated pneumonia. Develop and implement an oral hygiene program which includes utilize of an antiseptic agent.   Mori et al. (2006) compared ii large groups of ICU, mechanically ventilated patients. Twelve hundred and forty eight patients received prescribed oral care three times daily. Six hundred and xxx vii patients had not received oral care during an before infirmary period of stay and were used as historical controls. The incidence of VAP was significantly reduced for the oral care grouping compared to the non-oral intendance command group (iii.9 versus x.4).

Chlorhexidine oral rinse is an antimicrobial rinse which has widely been included every bit office of the routine oral intendance program for patients with tracheostomy and or mechanical ventilation, withal the impact has been debated.   Results from a Cochrane Review (2016) indicated that randomized controlled studies demonstrated chlorhexidine mouthwash or gel, reduces the risk of VAP compared to placebo or usual intendance from 24% to xviii%.  An updated meta-analysis focusing on double-blind studies in non-cardiac surgery patients showed that information technology had no bear upon on VAP rates or duration of mechanical ventilation or duration of ICU stay (Klompis, 2017).  It is even so widely used in VAP protocols for the intubated patient.

Hospitals are too including VAP bundles that include oral hygiene.  In a written report showing reduced VAP charge per unit afterward implementing a VAP packet that included head top, oral chlorhexidine gel, sedation interruptions and a ventilator weaning protocol (Moris, Ac et al, 2011).

Prevention of Gastric Colonization

The CDC (2003) does non have a recommendation for the preferential utilize of sucralfate, H2-antagonists, and/or antacids for stress-bleeding prophylaxis in patients receiving mechanically assisted ventilation.  There is also no recommendation past the CDC for the routine selective decontamination of the digestive tract of all critically ill, mechanically ventilated, or ICU patients or routinely acidifying gastric feedings.  The Intensive Care Social club (ICS) (2016) as well indicates that there is insufficient prove to give a clear recommendation of the use of gastrointestinal stress ulcer prophylaxis and the potential protective benefits of enteral feeding. The ICS recommend consideration of the risk contour of GI haemorrhage in each patient with judicious apply of gastrointestinal stress ulcer prophylaxis in patients considered to be at risk of GI bleeding.

Summary

Patients with tracheostomy and/or mechanical ventilation are at high run a risk for infection.  Health care workers should be educated on standard infection control methods (manus hygiene, personal protective equipment) too as specific methods for these loftier take a chance patients including suctioning procedure, tracheostomy tube intendance, humidification, equipment cleaning, oral care, sedation interruption, and, if feasible, weaning and decannulation.  Protocols for each method are recommended to standardize the approach in each facility.

For Covid-19 specific infection command recommendations delight cheque our article, Covid-xix Tracheostomy and Mechanical Ventilation.  The CDC and WHO too have recommendations regarding Covid-19 that are rapidly changing.

What to Read Side by side on Tracheostomy Education

Resource:

Birk R, Händel A, Wenzel A, et al. Heated air humidification versus cold air nebulization in newly tracheostomized patients.Head Neck. 2017;39(12):2481–2487. doi:10.1002/hed.24917

Centers for Illness Command.  Guidenline for Paw Hygiene in Healthcare Settings.  Morbidity and Mortality Weekly study.

Durbin CG. Early complications of tracheostomy. RespirCare 2005; 50: 511-5.

Hellyer, TP, Ewan, V, Wilson, P, & Simpson, AJ (2016). The Intensive Care Social club recommended bundle of interventions for the prevention of ventilator-associated pneumonia.Journal of the Intensive Care Society,17(3), 238–243. https://doi.org/10.1177/1751143716644461

Huggins, P., Tuomi, S. & Immature, C. Dysphagia (1999) 14: 157. https://doi.org/10.1007/PL00009598

Lepainteur, M et al.  Gamble factors for respiratory tract bacterial colonization in adults with neuromuscular or neurological disorders and chronic tracheostomy.Respiratory Medicine, Volume 152, 32 – 36

Mori, H., Hirasawa, H., Oda, Southward. et al. Intensive Intendance Med (2006) 32: 230. https://doi.org/10.1007/s00134-005-0014-4

Pryor, Lee N. et al. Bear upon of nasogastric tubes on swallowing physiology in older, healthy subjects: A randomized controlled crossover trial. Clinical Diet, Volume 34, Issue four, 572 – 5

Terragni PP, Antonelli One thousand, Fumagalli R, et al. Early vs Late Tracheotomy for Prevention of Pneumonia in Mechanically Ventilated Adult ICU Patients :A Randomized Controlled Trial.JAMA. 2010;303(15):1483–1489. doi:10.1001/jama.2010.47

Timsit JF, Esaied W, Neuville M, Bouadma L, Mourvllier B. Update on ventilator-associated pneumonia.F1000Res. 2017;6:2061. Published 2022 Nov 29. doi:10.12688/f1000research.12222.1

salgadothaventinsom.blogspot.com

Source: https://www.tracheostomyeducation.com/infection-control-issues-in-caring-for-patients-with-tracheostomy/#:~:text=Proper%20care%20including%20cleaning%20of,and%20after%20tracheostomy%20tube%20care.