The Effects of Tracheal Orientation on the Development of Ventilator

The Effects of Tracheal Orientation on the Development of Ventilator

Associated Pneumonia: an experimental study

Electronic Supplementary Material

Additional Materials and methods

This study was approved and conducted at the National Institutes of Health Animal Research Laboratory, BethesdaMD, USA.

Study groups

Twenty-six adult female Yucatan mini-pigs were randomized into 4 groups:

A) TracheaUp: eight pigs were mechanically ventilated in prone position for 72 hours with an orientation of trachea 45° above horizontal. Two of these eight pigs received enteral feeding through an orogastric tube.

B) TracheaDown72: six pigs were mechanically ventilated in prone position for 72 hours with the trachea oriented 10° below horizontal.

C) TracheaDown72F: six pigs were mechanically ventilated in prone position for 72 hours with the trachea oriented 10° below horizontal and received enteral feeding through an orogastric tube.

D) TracheaDown168F: pigs were mechanically ventilated in prone position for 168 hours with the trachea oriented 10° below horizontal and received enteral feeding through an orogastric tube.

Tracheal orientation

Figure 1 (panel a and b) shows the swine positions used to obtain an orientation of trachea/endotracheal tube above or below horizontal. Figure 1 (panel c) shows a representative swine tracheal fluoroscopy, which highlights the relative space orientation of the neck and the extrathoracic and intrathoracic trachea. The extrathoracic trachea (inside the neck) proceedsubstantially parallel to theventral wallof the neck, therefore in prone position, the natural position for pigs, is substantially horizontal while entering into the thorax turns backward towards the spine creating an angle around 11°. In the group TracheaUp, to achieve an orientation of the trachea of 45° above horizontal we oriented the head of the bed 30° above horizontal and we placed a foam pillow beneath the head. Such position mimics the semirecumbent position in humans. In group TracheaDown72, TracheaDown72F and TracheaDown168F to achieve an orientation of the trachea of 10° below horizontal we tilted the head of the bed 10° below horizontal.

Animal preparation

Anesthesia was maintained with a continuous infusion of propofol (2-6 mg/kg/hours), and fentanyl (2-20 mcg/kg/h). Carotid artery and internal jugular vein were surgically cannulated under strict aseptic conditions. A pulmonary artery catheter was positioned in 6 pigs kept in the semirecumbent position and in six pigs ventilated with the trachea oriented 10° below horizontal for 72 hours without enteral feeding.

Animal handling

The pigs were intubated mechanically ventilated with a tidal volume of 6-8 ml/Kg, respiratory rate of about 14 breaths/minute (range 10-20 breaths/minute) and 5 cmH2O of PEEP. Ventilation was adjusted to maintain arterial partial pressure of CO2 (PaCO2) around 40 mmHg. The endotracheal cuff pressure was maintained at 25-30 cm H2O. Inspiratory gases were conditioned by use of two heated humidifiers (Fisher & Paykel Healthcare Inc, Laguna Hills, CA and CONCHATHERM III® Heated Humidifier) in series. The inspiratory line was insulated with foam rubber. Lactate Ringer's and 0.9% NaCl in 1:1 ratio were administrated at 1-3 ml/kg/hour. Endotracheal suctioning was performed every 6 hours by means of an open tracheal suction system.No antibiotics were administered at least 1 month before as well as throughout the study.

Data collection

Arterial and mixed venous blood gases were sampled at least every 12 hours or when clinically indicated. At the same times, blood samples for complete blood cells counts and electrolytes were obtained. Hemodynamic and ventilatory parameters were recorded. Chest x-rays were taken after the animal preparation, when clinically indicated and before the autopsies.

Enteral nutrition

Enteral nutrition (Osmolite, Ross Nutrition, Abbott Laboratories, Columbus, Ohio, diluted 1:1 with tap water) was infused (30 ml/h) via an oro-gastric tube in the six pigs ventilated with the trachea oriented 10° below horizontal for 72 hours (TracheaDown72F), in six pigs ventilated with the trachea oriented 10° below horizontal for 168 hours (TracheaDown168F) and in two pigs ventilated for 72 hours in semirecumbent position. Each episode of regurgitation was recorded. We diluted the enteral feeds with water (1:1) after noting that full strength feeds agglomerate in the stomach of the first two pigs studied.

Microbiology and Pathology

Mouth swabs were collected after animal preparation and before autopsy. Gastric contents swabs were collected after preparation in pigs that had an orogastric tube placed and at the time of the autopsy in all pigs. Pigs were sacrificed upon the end of the study period, or after development of severe respiratory failure (defined as a PaO2/FIO2 ratio < 100 mmHg).

The following method was used to obtain lung samples:

After sacrifice the ETT was clamped to isolate the respiratory system from possible bacterial contamination.
The chest of the pig was saturated with a solution of betadine.
With a strict aseptic technique the thorax was opened and the lung and the trachea were exposed.
With the lungs in-situ we clamped the intratoracic portion of the trachea and the main bronchi to avoid movement of secretions from one lung to the other.
We remove aseptically the lungs and put the lungs on sterile drapes.
For each lobe we used two different forceps and two different scalpel blades: the first pair of forceps/scalpel blade was used to cut the surface of lobe while the second pair of forceps/scalpel was used to take a small sample for the interior of the lobe. This method was used to avoid cross-contamination between the exterior and the interior of the lung.
The sample was put in a sterile vial with about 1 ml of sterile saline solution and immediately immersed in an insulated container with wet ice.
After all samples were collected, they were immediately sent to the microbiological laboratory for quantitative and qualitative cultures.

Lung samples for histological analysis were obtained from 4 pigs in group TracheaUp and 4 pigs in the group TracheaDown168F to confirm the diagnosis of pneumonia.

Diagnosis of pneumonia

Pneumonia was defined as the occurrence of new pulmonary opacities on the chest x-ray associated with hypoxemia, presence of purulent tracheal secretions, gross findings suggestive of pneumonia at the autopsy, microbiological documentation of bacterial colonization and, when available, histological evidence of pneumonia.

We excluded temperature and white blood cells count from the diagnosis of pneumonia. Pig temperature was maintained around 38 degrees with a servo-controlled thermal blanket.

Statistical methods

The two pigs in group TracheaUp receiving enteral feeding were treated as a separate group in the analysis aimed at defining the determinants of bacterial colonization (Fisher-Freeman-Halton test, exact logistic regression, Poisson regression) since the presence/absence of enteral feeding had been independently associated with the development of pneumonia while in all the other analysis, they were grouped with the other 6 pigs ventilated with an orientation of trachea 45° above horizontal. We made this choice because the two pigs with feeding with an orientation of trachea 45° above horizontal behave as the six pigs with an orientation of trachea 45° above horizontal without feeding. We categorized the existence of bacterial colonization as either present or absent. The Fisher-Freeman-Halton test (a multivariate version of the Fisher exact test) was used with exact p-values to compare the 5 groups(TracheaUp, TracheaUp with feeding, TracheaDown72, TracheaDown72F, TracheaDown168F) in terms of frequency of bacteria colonization by location (trachea tip, tr. carina, right upper lobe, right medium lobe, right lower lobe, left upper lobe, left medium lobe, left lower lobe). We also compared the groups by colonization at any of the lung locations. To minimize false positive results, we performed pairwise comparisons between groups only at trachea carina and at any lung location. The exact logistic regression was used to identify predictors of bacterial colonization at any lung location. Predictors considered are: time (72 or 168 hours), feeding (Y or N), and trachea orientation (Up: 45° above horizontal, Down: 10° below horizontal); these same variables were used to predict the number of lung sites (1 to 6) colonized with bacteria using a Poisson regression. For continuous measurement variables, the groups were compared using the Kruskal-Wallis test; if the overall test was significant at the 0.05 level then the pairwise comparisons were performed using the Mann-Whitney test. The p-values were conservatively adjusted for the multiple comparisons using the Bonferroni correction. The Spearman’s correlation was used to associate the presence of bacteria in the lungs and upper locations (tr. tip and carina). We have created two new variables for the six lung locations, the combined total count and presence/absence at any location. For the top locations we created a binary variable based on the presence/absence of colonization. A similar correlation analysis as above was performed using mouth and stomach locations, where the level of bacteria was coded as 0= none, 1=light or medium or moderate and 2=many or heavy. The total numbers of unique bacteria and the relationship between mouth, trachea tip and lungs found at autopsy from the four groups studied are shown in 4-variable Karnaugh maps.

The analysis was performed with the SAS software, version 8.02 and the R software ( (see also the Statistical in the Electronic Supplementary Material).

Additional results

Correlation of bacteria presence in the lungs and in the trachea

Spearman`s correlation between bacteria found in the lung lobes and bacteria found at the trachea (both at the level of the ETT tip and carina) was significant. It is summarized as follows: the presence/absence of a given bacterium in the trachea (ETT tip and/or carina) vs. presence/absence of a given bacterium in the lungs, r=0.154, p<0.0001; the colonization at the trachea carina versus total number of bacteria in the lungs, r=0.735, p<0.0001, and the colonization at the ETT tip versus total number of bacteria in the lungs, r=0.405, p<0.0001. When we repeated the analysis within each group, only the TracheaUp group had significant correlations between the bacteria found in the trachea and the bacteria found in the lungs. These data are summarized as follows: the presence/absence of a given bacterium in the trachea (ETT tip and/or carina) vs. presence/absence of a given bacterium in the lungs, r=0.789, p<0.0001, the colonization at the trachea carina vs. total number of bacteria in the lungs, r=0.835, p<0.0001 and the colonization at the ETT tip vs. total number of bacteria in the lungs, r=0.689, p<0.0001. We did not find any significant correlation between the bacteria found in the mouth and in the stomach to the bacteria found in the lungs (see Table 7 and 8 in the ESM).

Table 3 – Gas exchange

Trachea Down 168 F / Trachea Down 72 F / Trachea Down 72 / Trachea Up / p value
pH / Start of Experiment
End of Experiment
Delta (End - Start) / 7.466±0.029
7.502±0.016
0.036±0.025 / 7.508±0.036
7.554±0.018
0.045±0.044 / 7.488±0.069
7.520±0.042
0.031±0.066 / 7.497±0.041
7.438±0.113
-0.059±0.122 / p = 0.17
PaO2/FIO2 / Start of Experiment
End of Experiment
Delta (End - Start) / 573±110
452±61
-121±100* / 511±23
488±16
-24±33* / 565±50
496±28
-69±53* / 530±42
132±139
-398±158 / p < 0.01
PaCO2 / Start of Experiment
End of Experiment
Delta (End - Start) / 40±3
41±3
1±5 / 41±4
38±2
-2±4 / 40±6
41±3
1±5 / 40±4
52±17
12±15 / p = 0.10
SaO2 (%) / Start of Experiment
End of Experiment
Delta (End - Start) / 99.8±0.4
99.9±0.0
0.2±0.4* / 100.0±0.1
99.9±0.2
-0.1±0.1* / 99.9±0.0
99.9±0.0
0.0±0.0* / 100.0±0.0
86.4±15.4
-13.6±15.4 / p < 0.001
HCO3- (arterial) / Start of Experiment
End of Experiment
Delta (End - Start) / 28.9±2.0
32.6±2.7
3.7±3.7 / 33.3±2.5
34.6±2.5
1.3±2.8 / 30.1±2.2
33.9±3.8
3.9±3.1 / 31.0±3.0
35.0±5.5
4.0±3.7 / p = 0.40
BE (arterial) / Start of Experiment
End of Experiment
Delta (End - Start) / 5.3±2.0
9.3±2.5
4.0±3.4 / 9.8±2.4
11.6±2.2
1.9±2.9 / 6.7±2.9
10.3±3.7
3.7±2.7 / 7.5±2.8
9.6±5.1
2.1±4.4 / p = 0.61

* p < 0.05 vs Trachea Up

Start of experiment refers to blood gas data collected 6 hour after the experimental orientation of the trachea was obtained. End of experiment refers to the last set of data collected, after the scheduled time (72 or 168 hours) or immediately before sacrifice.

List of abbreviations: PaO2/FIO2 = arterial partial pressure of oxygen/inspired oxygen fraction. SaO2 = arterial saturation of hemoglobin. BE = standard base excess. Changes occurred across the experimental period were compared between groups with the Kruskal- Wallis test; for multiple comparison we used Wilcoxon test and corrected the p-value for the number of multiple comparisons performed. * = p < 0.05 vs TracheaUp.

Table 4 – Ventilatory parameters

Trachea Down 168 F / Trachea Down 72 F / Trachea Down 72 / Trachea Up / p value
Tidal Volume (insp) (ml) / Start of Experiment
End of Experiment
Delta (End - Start) / 306±53
300±51
-6±8 / 248±45
247±45
-1±12 / 265±27
258±28
-7±5 / 249±35
210±44
-39±61 / p = 0.81
Respiratory rate (breaths/min) / Start of Experiment
End of Experiment
Delta (End - Start) / 13±1
13±2
0±2* / 16±3
15±2
-1±2* / 13±2
14±2
0±2* / 15±2
29±16
15±15 / p < 0.01
Minute ventilation (l/min) / Start of Experiment
End of Experiment
Delta (End - Start) / 4±1
4±0
-0±1 / 4±1
4±1
-0±1 / 4±1
3±0
-0±1 / 4±0
5±2
2±2 / p = 0.10
Peak pressure (cmH2O) / Start of Experiment
End of Experiment
Delta (End - Start) / 21±2
24±2
3±2 / 18±2
21±2
3±3 / 18±1
20±2
3±2 / 18±2
30±8
11±8 / p = 0.06
Plateau pressure (cmH2O) / Start of Experiment
End of Experiment
Delta (End - Start) / 18±2
20±2
1±2 / 16±1
17±2
1±2 / 16±2
18±2
2±1 / 16±1
23±5
7±6 / p = 0.05
Mean airway pressure (cmH2O) / Start of Experiment
End of Experiment
Delta (End - Start) / 10±1(n=5)
11±1(n=5)
1±2(n=5)* / 9±0
9±1
0±1* / 8±0
9±1
0±0* / 8±1
12±2
3±2 / p < 0.01
PEEP (cmH2O) / Start of Experiment
End of Experiment
Delta (End - Start) / 6±1
6±1
-1±1 / 5±1
5±0
0±1 / 5±0
5±0
0±0 / 5±0
6±4
1±4 / p = 0.54
CPL (respiratory system) (L/cmH2O) / Start of Experiment
End of Experiment
Delta (End - Start) / 25±2
22±3
-4±3* / 23±4
21±5
-2±3* / 25±3
20±3
-4±2* / 24±5
14±5
-10±8 / p = 0.03

*p < 0.05 vs Trachea Up

Start of experiment refers to ventilatory parameters data collected 6 hour after the experimental orientation of the trachea was obtained. End of experiment refers to the last set of data collected, after the scheduled time (72 or 168 hours) or immediately before sacrifice.

Respiratory system compliance was calculated as tidal volume / (plateau pressure - PEEP)

List of abbreviations: PEEP = Positive End Expiratory Pressure CPL = respiratory system compliance

Changes occurred across the experimental period were compared between groups with the Kruskal- Wallis test; for multiple comparison we used Wilcoxon test and corrected the p-value for the number of multiple comparisons performed. * = p < 0.05 vs TracheaUp.

Table 5 - Hemodynamics

Trachea Down 168 F / Trachea Down 72 F / Trachea Down 72 / Trachea Up / p value
Systolic arterial pressure (mmHg) / Start of Experiment
End of Experiment
Delta (End - Start) / 120±16
114±20
-6±12 / 138±23
139±18
1±11 / 110±14
109±14
-1±27 / 121±31
122±29
1±26 / p = 0.88
Diastolic arterial pressure (mmHg) / Start of Experiment
End of Experiment
Delta (End - Start) / 96±17
78±21
-18±15 / 107±22
108±18
1±16 / 78±11
78±13
0±22 / 85±24
85±30
-0±27 / p = 0.21
Mean arterial pressure (mmHg) / Start of Experiment
End of Experiment
Delta (End - Start) / 108±17
97±19
-11±13 / 120±23
123±18
3±15 / 95±12
94±13
-1±23 / 101±27
99±27
-2±27 / p = 0.53
Heart rate (beats/min) / Start of Experiment
End of Experiment
Delta (End - Start) / 102±9
97±14
-5±16 / 102±28
96±16
-6±22 / 76±7
97±20
21±24 / 91±21
116±25
25±36 / p = 0.08
Aminic support / Start of Experiment
End of Experiment
Delta (End - Start) / 0/6
0/6
0 / 0/6
0/6
0 / 0/6
0/6
0 / 0/8
2/8
2 / P = 0.22
Surrogate study fluid balance (ml) / 222±3521 / 938±1111 / 326±729 / 2473±1298 / P = 0.06

Start of experiment refers to hemodynamic parameters collected 6 hour after the experimental orientation of the trachea was obtained. End of experiment refers to the last set of data collected, after the scheduled time (72 or 168 hours) or immediately before sacrifice. Surrogate fluid balance was calculated including as input infusions, enteral nutrition and drugs and urine volume as output.

Table 6, Bacterial colonization (colony-forming units/g, CFU/g) of each single lobe and trachea of every animal, divided by group, at autopsy.

Pig / Bacterium / mouth / stomach / ETT tip / Carena / RUL / RML / RLL / LUL / LML
TracheaDown - 72 hours of mechanical Ventilation
5615 / ArH
StS
StS
PrR
EsC
ShF
PsS / Moderate
Moderate
No
Moderate
Moderate
No
No / No
No
No
No
Light
No
No / No
No
Moderate
No
No
Moderate
Moderate / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
5617 / EsC
StS
StP
KlS / Moderate
Moderate
No
No / Moderate
No
No
No / No
Moderate
Moderate
Moderate / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0
5623 / AcS
OkS
EsC
LaS
StC/G / No
No
Heavy
Heavy
Heavy / No
No
Light
No
Light / 1.00E+07
3.10E+06
0
0
0 / 1.20E+04
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0
5624 / SmM
EsC
PaA
PsS
CbS / Moderate
Moderate
Moderate
No
No / No
Light
Moderate
No
No / 0
0
0
1.10E+09
5.50E+108 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0
5662 / CbS
EnA
CbS
SmM
EsC / Moderate
No
No
Moderate
Moderate / No
No
Moderate
Moderate
No / 0
0
0
0
4.20E+06 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0 / 0
0
0
0
0
5653 / AeV
AcS
SmM
BaM
EsC
KlX / Heavy
No
Heavy
Moderate
Heavy
Heavy / No
No
No
Moderate
Heavy
Heavy / 0
3.50E+08
0
0
0
0 / 0
0
0
0
0
0 / 0
0
0
0
0
0 / 0
0
0
0
0
0 / 0
0
0
0
0
0 / 0
0
0
0
0
0 / 0
0
0
0
0
0 / 0
0
0
0
0
0
Trachea Down - 72 hours of mechanical Ventilation – Enteral Feeding
Pig / Bacterium / mouth / stomach / ETT tip / Carena / RUL / RML / RLL / LUL / LML / LLL
737 / EsC
StS
StU
PsA
SmM
BrB
ShH / No
No
Moderate
Heavy
No
Heavy
Moderate / Moderate
Moderate
No
No
No
No
No / 0
0
1.90E+06
6.40E+04
2.40E+08
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
795 / EsC
PaM
Shp
StVi / Heavy
No
Heavy
No / Moderate
No
No
Moderate / 5.00E+06
5.00E+06
3.00E+06
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0
826 / PaM
EsC
ArH
StVi
AeH
StS
Stn
StO / No
Heavy
No
No
Heavy
Moderate
Heavy
Heavy / No
Moderate
No
Light
No
No
No
No / 0
5.00E+07
1.00E+05
3.00E+05
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
816 / StL
SpP
PaM
EsC / Heavy
No
No
Heavy / No
No
No
No / 0
0
2.26E+07
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0
829 / StL
EsC
Shp
PaM / Heavy
Heavy
Heavy
No / Moderate
Moderate
No
No / 0
0
0
4.20E+07 / 0
0
0
9.09E+03 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0
7900 / EnF
EsC
LaR
KlO
EnM
StV
PaM / Moderate
Moderate
Moderate
Moderate
Moderate
No
No / No
No
No
No
No
Moderate
No / 0
0
0
0
0
0
1.60E+07 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
Trachea Down - 168 hours of mechanical Ventilation – Enteral Feeding
Pig / Bacterium / mouth / stomach / ETT tip / Carena / RUL / RML / RLL / LUL / LML / LLL
72-3 / StU
SmM
PaS
EsC
BaM
PrM
MoM
EnF
StC/G / No
No
No
Moderate
No
Heavy
Moderate
Moderate
Moderate / No
No
No
No
Moderate
Heavy
Moderate
Moderate
Moderate / 0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0 / 2.30E+04
0
0
0
0
0
0
5.60E+03
0 / 0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
72-4 / EsC
PrM
StY
PsA
CbS
C/Ms
StS
StB / Moderate
Heavy
Moderate
No
No
No
No
No / Light
No
No
No
No
No
Moderate
Moderate / 2.50E+07
0
0
4.20E+07
6.10E+07
2.30E+08
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
72-5 / AeV
ShA
EsC
Lis
StC/G
PsA / No
Moderate
Heavy
No
No
Moderate / Heavy
No
Moderate
No
No
No / 0
0
0
6.30E+05
3.20E+04
4.00E+04 / 0
0
0
1.00E+08
6.00E+04
0 / 0
0
0
8.70E+05
0
0 / 0
0
0
0
0
0 / 0
0
0
0
0
0 / 0
0
0
0
0
0 / 0
0
0
0
0
0 / 0
0
0
4.00E+04
0
0
72-7 / PaM
StE
PrM
StC/G / No
No
Moderate
Heavy / No
Moderate
No
No / 1.10E+04
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0 / 0
0
0
0
827 / EsC
StL / Heavy
Heavy / No
Heavy / 5.00E+04
0 / 0
0 / 0
0 / 0
0 / 0
0 / 0
0 / 0
0 / 0
0
8073 / PsA
EsC
Stn
PrM
EnC
ShH
KlT
ShC
StC/G
ShS / Heavy
No
No
Heavy
Heavy
Heavy
Heavy
Heavy
Heavy
Moderate / No
Light
Light
No
No
No
No
No
No
No / 9.30E+07
0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
0
Trachea Up- 72 hours of mechanical ventilation
Pig / Bacterium / mouth / stomach / ETT tip / Carena / RUL / RML / RLL / LUL / LML / LLL
5620 / PaA
CbG
CbS
AeU
EsC
ShA / Moderate
No
No
No
Moderate
Moderate / n.a.
n.a.
n.a.
n.a.
n.a.
n.a. / 8.70E+04
1.30E+05
0
4.30E+04
0
0 / 0
0
1.60E+07
0
0
0 / 0
0
0
0
0
0 / 0
0
1.40E+06
0
0
0 / 0
0
5.20E+07
0
0
0 / 0
0
0
0
0
0 / 0
0
3.50E+05
1.00E+05
0
0 / 0
3.60E+03
3.10E+07
5.00E+06
0
0
5621 / CbS
SmM
CbG
OlU
LeS
EsC / No
Heavy
No
No
No
Moderate / No
No
No
No
Light
Light / 1.10E+08
0
5.00E+07
4.50E+07
0
0 / 2.20E+08
0
2.70E+06
0
0
0 / 9.30E+07
0
8.30E+05
0
0
0 / 2.70E+09
0
0
0
0
0 / 1.90E+09
0
0
0
0
0 / 1.50E+09
0
0
0
0
0 / 1.40E+09
0
0
0
0
0 / 2.80E+08
0
0
0
0
0
5639 / SmM
EsC
StU
StC
PaH
StC/G / No
Moderate
No
No
Moderate
Heavy / No
No
Moderate
Moderate
No
No / 1.20E+08
0
4.00E+07
0
0
0 / 1.60E+05
0
1.30E+05
0
0
0 / 8.40E+04
0
3.70E+03
0
0
0 / 4.40E+07
0
4.00E+06
0
0
0 / 1.30E+07
0
1.20E+06
0
0
0 / 5.00E+07
0
2.10E+07
0
0
0 / 8.90E+07
0
3.10E+07
0
0
0 / 2.20E+08
0
4.70E+07
0
0
0
5644 / EsC
SmM
StV
OkS
StC/G / Heavy
Heavy
No
No
No / Moderate
No
Light
No
No / 0
0
0
1.60E+09
4.00E+07 / 0
0
0
2.40E+09
4.30E+07 / 0
0
0
1.80E+08
2.30E+06 / 0
0
0
1.10E+09
2.80E+03 / 0
0
0
2.50E+08
5.60E+06 / 0
0
0
1.40E+07
1.10E+05 / 0
0
0
1.10E+09
1.30E+07 / 0
0
0
4.60E+06
3.00E+04
5652 / EsC
ShE
CbS
SmM
StC/G
EnF
ShA
PsS
Stn
StS / Heavy
No
Heavy
Heavy
Moderate
Moderate
Moderate
Moderate
No
No / Light
No
No
No
No
No
No
No
Light
Moderate / 2.90E+08
0
0
0
0
0
0
0
0
0 / 4.70E+03
0
0
0
0
0
0
0
0
0 / 1.70E+03
0
0
0
0
0
0
0
0
0 / 3.20E+03
0
0
0
0
0
0
0
0
0 / 1.20E+03
0
0
0
0
0
0
0
0
0 / 0
2.30E+03
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
0 / 0
0
0
0
0
0
0
0
0
0
5661 / ArP
CbS
AcS
SmM
EsC
LaL / Moderate
Heavy
Heavy
Heavy
Heavy
No / Moderate
Moderate
Heavy
Moderate
Heavy
Heavy / 3.40E+08
8.20E+08
4.80E+07
0
0
0 / 0
2.40E+08
4.40E+07
0
0
0 / 0
1.10E+09
5.60E+07
0
0
0 / 2.00E+07
5.30E+07
0
0
0
0 / 0
7.20E+08
8.00E+07
0
0
0 / 0
7.10E+06
1.00E+06
0
0
0 / 4.20E+07
5.90E+07
0
0
0
0 / 0
7.70E+07
4.70E+06
0
0
0
Trachea Up - 72 hours of mechanical ventilation – Enteral feeding
Pig / Bacterium / mouth / stomach / ETT tip / Carena / RUL / RML / RLL / LUL / LML / LLL
8057 / BrV
Stn
StI
StP
ArH
OkS
EsC
ViV
PsA
AeH
StB
EnF
ShS
StV
Yeast / No
No
No
No
No
No
Heavy
No
Heavy
Heavy
Heavy
Heavy
Heavy
No
No / No
No
No
No
No
No
No
No
No
No
No
No
No
Heavy
Heavy / 0
4.00E+08
0
0
0
5.20E+08
1.10E+07
0
0
0
0
0
0
0
0 / 3.10E+08
0
0
5.70E+06
0
0
0
2.80E+03
0
0
0
0
0
0
0 / 5.90E+07
0
0
3.70E+07
0
0
0
3.00E+03
0
0
0
0
0
0
0 / 1.20E+06
5.00E+06
0
0
0
0
0
0
0
0
0
0
0
0
0 / 8.70E+07
0
0
5.60E+07
0
0
0
0
0
0
0
0
0
0
0 / 1.00E+03
0
0
0
0
0
0
0
0
0
0
0
0
0
0 / 3.20E+03
0
1.10E+03
2.20E+03
0
0
0
0*
0
0
0
0
0
0
0 / 0
0
0
4.90E+03
1.20E+04
4.10E+04
0
0
0
0
0
0
0
0
0
8071 / PsA
StA
ArP
MiL / n.a.
n.a.
n.a.
n.a. / n.a.
n.a.
n.a.
n.a. / 1.30E+09
0
5.80E+09
5.00E+07 / 8.30E+08
1.60E+07
1.60E+06
7.90E+06 / 7.30E+03
1.50E+04
1.30E+06
5.10E+04 / 2.90E+06
5.30E+05
4.00E+07
5.30E+05 / 2.00E+06
1.70E+06
6.20E+07
2.80E+06 / 3.30E+04
3.80E+06
6.40E+06
2.70E+05 / 1.20E+06
2.90E+06
1.10E+07
1.00E+06 / 4.20E+06
5.80E+06
8.80E+07
1.10E+06

RUL, right upper lobe; RML, right middle lobe; RLL, right lover lobe; LUL, left upper lobe; LML, left middle lobe; LLL, left lover lobe; n.a., Not Avaiable; AcS, Acinetobacter sp; AeU, Aerococcus urinae; AeV, Aerococcus viridans; AeH, Aeromonas hydrophila; ArH, Arcanobacterium haemolyticum; ArP, Arcanobacterium pyogenes; BaM, Bacillus megaterium; BrB, Brevibacillus brevis; BrV, Brevundimonas vesicularis; C/Ms, Cellulomonas spp/Microbacterium spp; CbG, Corynebacterium genitalium; CbS, Corynebacterium sp; EnA, Enterobacter aeroges; EnM, Enterobacter amnigenus; EnC, Enterococcus casseliflavus; EnF, Enterococcus faecalis; EsC, Escherichia Coli; KlO, Klebsiella ornithinolytica; KlX, Klebsiella oxytica; KlS, Klebsiella sp; KlT, Klebsiella terrigena; LAL, Lactococcus lastis ssp cremoris; LaR, Lactococcus raffinolactis; LaS, Lactococcus sp; LeS, Leuconostoc sp; Lis, Listeria sp; MiL, Micrococcus luteus; MoM, Morganella morganiii; OkS, Oerskovia sp; OlU, Oligella ureolytica; PaS, Pantoea sp; PaA, Pasteurella aerogenes; PaH, Pasteurella haemolytica, PaM, Pasteurella multocida; PsS, Pasteurella sp; PrM, Proteus mirabilis; PrR, Providencia rettgeri; PsA, Pseudomonas aeruginosa; SpP, Sphingomonas paucimobilis; Shp, staphyloccoccus; ShA, Staphyloccoccus aureus; ShC, Staphylococcus capitis; ShE, Staphyloccus epidermidis; ShF, Staphylococcus felis; ShH, Staphylococcus haemolyticus; ShS, Staphylococcus simulans; SmM, Stomatococcus mucilaginosus; StA, Streptococcus agalactiae; StL, Streptococcus alpha; StB, Streptococcus bovis; StC, Streptococcus cristatus; StE, Streptococcus equinus; StC/G, Streptoccoccus group C/G; StI, Streptococcus intermedius; StO, Streptoccoccus Oralis; StY, Streptoccoccus Pyogenes; StP, Streptococcus porcinus; Stn, Streptococcus sanguinis; StS, Streptococcus species; StU, Streptococcus suis; StV, Streptoccoccus vestibularis; StVi, Streptococcus viridans; ViV, Vibrio vulnificus;