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Prevention of Ventilator-Associated Pneumonia
- Harold R. Collard, MD;
- Sanjay Saint, MD, MPH; and
- Michael A. Matthay, MD
- From University of Colorado Health Sciences Center, Denver, CO 80262; Ann Arbor Veterans Affairs Medical Center and the University of Michigan Health System, Ann Arbor, MI 48109; and University of California, San Francisco, San Francisco, CA 94143.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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IN RESPONSE:
Systematic reviews aim to summarize existing data identified through specified selection criteria and, at times, make recommendations on the basis of these data. We believe that well-done systematic reviews illustrate the strength of evidence-based medicine, not the “absurdity.” Recommendations in our article were made not on the basis of our preferences but after careful evaluation of the evidence.
Ricard and Dreyfuss contest our review of 2 meta-analyses comparing sucralfate with H2-antagonists, claiming the studies reached opposite conclusions (1, 2). This is incorrect. Both studies found sucralfate to be associated with a decreased incidence of ventilator-associated pneumonia compared with H2-antagonists. Whether clinicians need to routinely prevent stress-related upper gastrointestinal bleeding in critically ill patients—a question not addressed by our review—is controversial. Ricard and Dreyfuss question our conclusion that aspiration of subglottic secretions may benefit patients who require mechanical ventilation for more than 72 hours because of studies showing that this technique reduces early-onset ventilator-associated pneumonia (pneumonia developing within 4 to 5 days of intubation). Many patients who require mechanical ventilation for longer than 72 hours develop early-onset ventilator-associated pneumonia, and it is these patients who appear to benefit most from aspiration of subglottic secretions.
Ricard and Dreyfuss's statement that we “did not apply so-called evidence-based medicine when it did not fit [our] beliefs” is groundless; there is ample evidence to suggest that the use of selective decontamination of the digestive tract may increase antimicrobial resistance (3, 4). Although we appreciate the additional information Ricard and Dreyfuss provided about the use of heat and moisture exchangers, the assertion that we misstated the methods in the study by Davis and colleagues (5) is incorrect. Davis and colleagues randomly assigned patients to groups in which heat and moisture exchangers were changed every 24 or 120 hours. We stand by our calculation of 120 hours as 5 days. Finally, Ricard and Dreyfuss state that we ignored randomized, controlled trials showing that noninvasive ventilation reduces ventilator-associated pneumonia. Although our search strategy identified several studies of noninvasive ventilation (as well as studies of many other strategies), none met our inclusion criteria.
We attempted to provide an unbiased, comprehensive review of the literature on strategies to prevent ventilator-associated pneumonia. Although evidence-based medicine certainly has its flaws, we hope that our review helps clinicians identify practices that may help reduce the occurrence of this highly morbid condition.
Harold R. Collard, MD
University of Colorado Health Sciences Center; Denver, CO 80262
Sanjay Saint, MD, MPH
Ann Arbor Veterans Affairs Medical Center and the University of Michigan Health System; Ann Arbor, MI 48109
Michael A. Matthay, MD
University of California, San Francisco; San Francisco, CA 94143
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
