***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES To characterize the current economic burden of ventilator-associated pneumonia ( VAP ) and to determine which services increase the cost of VAP in North American hospitals . DESIGN AND SETTING We performed a retrospective , matched cohort analysis of mechanically ventilated patients enrolled in the North American Silver-Coated Endotracheal Tube ( NASCENT ) study , a prospect i ve , r and omized study conducted from 2002 to 2006 in 54 medical centers , including 45 teaching institutions ( 83.3 % ) . METHODS Case patients with microbiologically confirmed VAP ( n = 30)were identified from 542 study participants with cl aims data and were matched by use of a primary diagnostic code , and subsequently by the Acute Physiology and Chronic Health Evaluation II score , to control patients without VAP ( n = 90 ) . Costs were estimated by applying hospital-specific cost-to-charge ratios based on all-payer inpatient costs associated with VAP diagnosis-related groups . RESULTS Median total charges per patient were $ 198,200 for case patients and $ 96,540 for matched control patients ( P < .001 ) ; corresponding median hospital costs were $ 76,730 for case patients and $ 41,250 for control patients ( P = .001 ) . After adjusting for diagnosis-related group payments , median losses to hospitals were $ 32,140 for case patients and $ 19,360 for control patients ( P = .151 ) . The median duration of intubation was longer for case patients than for control patients ( 10.1 days vs 4.7 days ; P < .001 ) , as were the median duration of intensive care unit stay ( 18.5 days vs 8.0 days ; P < .001 ) and the median duration of hospitalization ( 26.5 days vs 14.0 days ; P < .001 ) . Examples of services likely to be directly related to VAP and having higher median costs for case patients were hospital care ( P < .05 ) and respiratory therapy ( P < .05 ) . CONCLUSIONS VAP was associated with increased hospital costs , longer duration of hospital stay , and a higher number of hospital services being affected , which underscores the need for bundled measures to prevent VAP . TRIAL REGISTRATION NASCENT study Clinical Trials.gov Identifier : NCT00148642 Objective Although quantitative microbiological cultures of sample s obtained by bronchoscopy are considered the most specific tool for diagnosing ventilator-associated pneumonia , this labor-intensive invasive technique is not widely used . The  Clinical Pulmonary Infection Score ( CPIS ) , a diagnostic algorithm that relies on easily available clinical , radiographic , and microbiological criteria , could be an attractive alternative for diagnosing ventilator-associated pneumonia . Initially , the CPIS scoring system was vali date d upon 40 quantitative cultures of bronchoalveolar lavage fluid from 28 patients , and only few other studies have evaluated this scoring system since then . Therefore , little is known about the accuracy of this score . Design We compared the scores of a slightly adjusted CPIS with results from quantitative cultures of bronchoalveolar lavage fluid in 99 consecutive patients with suspicion of ventilator-associated pneumonia , using growth of ≥104 cfu/ml in bronchoalveolar lavage fluid as a cut-off for diagnosing ventilator-associated pneumonia . In addition , the CPIS were calculated for 52 patients by two different intensivists to determine the inter-observer variability . Results Ventilator-associated pneumonia was diagnosed in 69 ( 69.6 % ) patients . When using a CPIS > 5 as diagnostic cutoff , the sensitivity of the score was 83 % and its specificity was 17 % . The area under the Receiver Operating Characteristic curve was 0.55 . The level of agreement for prospect ively measured Clinical Pulmonary Infection Score ( ≤6 and > 6 ) was poor ( kappa = 0.16 ) . Conclusions When compared to quantitative cultures of bronchoalveolar lavage fluid , the CPIS has a low sensitivity and specificity for diagnosing ventilator-associated pneumonia with considerable inter-observer variability Background Ventilator-associated pneumonia ( VAP ) is the most common infection in intubated critically ill patients . Microaspiration of the contaminated gastric and oropharyngeal secretions is the main mechanism involved in the pathophysiology of VAP . Tracheal cuff plays an important role in stopping the progression of contaminated secretions into the lower respiratory tract . Previous in vitro studies suggested that conical cuff shape might be helpful in improving tracheal sealing . However , clinical studies found conflicting results . The aim of this study is to determine the impact of conical tracheal cuff shape on the microaspiration of gastric contents in critically ill patients . Methods / Design This prospect i ve cluster r and omized controlled crossover open-label trial is currently being conducted in ten French intensive care units ( ICUs ) . Patients are allocated to intubation with a polyvinyl chloride ( PVC ) st and ard (barrel)-shaped or a PVC conical-shaped tracheal tube . The primary objective is to determine the impact of the conical shaped tracheal cuff on abundant microaspiration of gastric contents . Secondary outcomes include the incidence of microaspiration of oropharyngeal secretions , tracheobronchial colonization , VAP and ventilator-associated events . Abundant microaspiration is defined as the presence of pepsin at significant level ( > 200 ng/ml ) in at least 30 % of the tracheal aspirates . Pepsin and amylase are quantitatively measured in all tracheal aspirates during the 48 h following inclusion . Quantitative tracheal aspirate culture is performed at inclusion and twice weekly . We plan to recruit 312 patients in the participating ICUs . Discussion BEST Cuff is the first r and omized controlled study evaluating the impact of PVC tracheal-cuff shape on gastric microaspirations in patients receiving invasive mechanical ventilation . Enrollment began in June 2014 and is expected to end in October 2015.Trial registration Clinical Trials.gov Identifier : NCT01948635 ( registered 31 August 2013 ) BACKGROUND Ventilator-associated pneumonia ( VAP ) is an important cause of morbidity and mortality in ventilated critically ill patients . PURPOSE To develop evidence -based guidelines for the prevention of VAP . DATA SOURCES MEDLINE , EMBASE , CINAHL , and the Cochrane Data base of Systematic Review s and Register of Controlled Trials . STUDY SELECTION The authors systematic ally search ed for all relevant r and omized , controlled trials and systematic review s on the topic of prevention of VAP in adults that were published from 1980 to October 1 , 2006 . DATA EXTRACTION Independently and in duplicate , the panel scored the internal validity of each trial . Effect size , confidence intervals , and homogeneity of the results were scored using predefined definitions . Scores for the safety , feasibility , and economic issues were assigned based on consensus of the guideline panel . LEVELS OF EVIDENCE The following statements were used : recommend , consider , do not recommend , and no recommendation due to insufficient or conflicting evidence . DATA SYNTHESIS To prevent VAP : We recommend : that the orotracheal route of intubation should be used for intubation ; a new ventilator circuit for each patient ; circuit changes if the circuit becomes soiled or damaged , but no scheduled changes ; change of heat and moisture exchangers every 5 to 7 days or as clinical ly indicated ; the use of a closed endotracheal suctioning system changed for each patient and as clinical ly indicated ; subglottic secretion drainage in patients expected to be mechanically ventilated for more than 72 hours ; head of bed elevation to 45 degrees ( when impossible , as near to 45 degrees as possible should be considered ) . Consider : the use of rotating beds ; oral antiseptic rinses . We do not recommend : use of bacterial filters ; the use of iseganan We make no recommendations regarding : the use of a systematic search for sinusitis ; type of airway humidification ; timing of tracheostomy ; prone positioning ; aerosolized antibiotics ; intranasal mupirocin ; topical and /or intravenous antibiotics .  CONCLUSION There are a growing number of evidence -based strategies for VAP prevention , which , if applied in practice , may reduce the incidence of this serious nosocomial infection The present study compared changes in cuff pressure by head and neck position between  high-volume low-pressure ( HVLP ) and taper-shaped ( taper ) cuffs  in a prospect i ve r and omized clinical trial . Methods . Forty patients were intubated using tracheal tubes with either HVLP ( n = 20 ; HVLP group ) or taper-shaped ( n = 20 ; Taper group ) cuffs .  Initial cuff pressure was adjusted to 15 , 20 , or 25 cmH2O in the neutral position . Cuff pressure was evaluated after changing the head and neck positions to flexion , extension , and rotation . Results . Cuff pressure significantly increased with flexion in both HVLP and Taper groups at all initial cuff pressures . It significantly increased with extension in the HVLP group , but not in the Taper group . Cuff pressure did not significantly differ with rotation in either group and was significantly smaller in the Taper group during flexion and extension than in the HVLP group , regardless of initial cuff pressure . Conclusion . Cuff pressure changes with head and neck flexion and extension were smaller in the Taper group than in the HVLP group . Our results highlight the potential for taper cuffs to prevent excessive cuff pressure increases with positional changes in the head and neck . This trial is registered with UMIN000016119 UNLABELLED Tracheal secretion leakage might lead to ventilator-associated pneumonia . St and ard tracheal tube cuffs are cylindrical in shape . Bronchial tree aspiration is observed in the presence of leakage past tracheal tube cuffs . The new TaperGuard tracheal tube has a cuff in the shape of a cone , preventing from the development of microtubules and microaspiration . The aim of the study was to compare st and ard tracheal tube cuffs with TaperGuard tubes , in terms of protection from microaspiration under general anesthesia . MATERIAL AND METHODS The observational study evaluated incidents of leakage during general anesthesia with intubation and mechanical ventilation in patients with significant obesity . The study group comprised 20 patients with the BMI > 40 kg/m2 subjected to elective surgery under general anesthesia with intubation and mechanical ventilation , r and omly divided into two subgroups : st and ard tracheal tube and TaperGuard tube . RESULTS In 4 of 10 patients with st and ard tracheal tubes we observed leakage around the cuff . In case of TaperGuard tubes no such leakage was observed . CONCLUSION TaperGuard tubes protect against microaspirations , while st and ard tracheal tubes have no such properties BACKGROUND Although the cuff of tracheal tubes can reduce airflow leakage and prevent aspiration , excessive intracuff pressure can cause tracheal mucosal injury .  Robot-assisted laparoscopic surgery ( RALS ) can increase intracuff pressure by the Trendelenburg position and pneumoperitoneum . The aim of our current study was to investigate the effect of tracheal cuff shape on the intracuff pressure increase by comparing two different-shaped cuffs during RALS . MATERIAL S AND METHODS Ninety-eight patients undergoing RALS were allocated r and omly into two groups ( tapered-shaped cuff [ TSC ] and cylindrical-shaped cuff [ CSC ] groups ) . The intracuff pressure was measured at nine specific time points : after intubation , immediately after surgical preparation ( Trendelenburg position with CO2 insufflation ) , at 5 , 10 , 15 , 30 , 60 , and 90 minutes after surgical preparation , and at the end of surgery . Postintubation airway symptoms were measured by assessing sore throat , hoarseness , and excessive cough 1 hour after postanesthesia care unit admission . RESULTS Intracuff pressure significantly increased during surgery in both groups . The trend of intracuff pressure change decreased in the TSC group compared with the CSC group , although no statistically significant changes were found ( P=.450 ) . Also , there were no statistically significant differences in the postintubation airway symptom between the two groups . CONCLUSIONS The TSC tube has a tendency to decrease intracuff pressure change compared with the CSC tube during RALS . However , neither of them was beneficial in preventing intraoperative intracuff pressure increase during RALS Background The primary objective of this study was to determine the efficiency of a pneumatic device in controlling cuff pressure ( Pcuff ) in patients intubated with polyurethane-cuffed tracheal tubes . Secondary objectives were to determine the impact of continuous control of Pcuff , and cuff shape on microaspiration of gastric contents . Methods Prospect i ve r and omized controlled study . All patients requiring intubation and mechanical ventilation ≥48 h were eligible . The first 32 patients were intubated with tapered polyurethane-cuffed , and the 32 following patients were intubated with cylindrical polyurethane-cuffed tracheal tubes  . Patients r and omly received 24 h of continuous control of Pcuff using a pneumatic device ( Nosten ® ) , and 24 h of routine care of Pcuff using a manometer . Target Pcuff was 25 cmH2O . P 
    Output:
    
Conclusions : Application of tapered endotracheal tube cuffs did not reduce hospital-acquired pneumonia incidence among ICU and postoperative patients .