Wren, Boyle, and the origins of intravenous injections and the Royal Society of London.

impact on VAP. Second, we disagree with the opinion that the orientation of the endotracheal tube below horizontal will result in reduced incidence of VAP for the reason that it is based on insufficient clinical data: three experimental animal (sheep) studies, a randomized controlled trial with 60 ventilated infants that compared the tracheal colonization rate and not the VAP incidence in supine versus lateral position, and unpublished observations in adult patients. The possible body positions for orientation of the endotracheal tube below horizontal are head-down (Trendelenburg) position and lateral head-down positions. In our opinion, these positions are uncomfortable, unsafe for patients with raised intracranial pressure, and inappropriate for patients in the weaning process. Furthermore, there is evidence that the semirecumbent position is the optimal body position for VAP prevention in critically ill patients. Drs. Sathishkumar and Fassl report the advantages of the LoTrachTM tube (Hi-Lo Evac; Mallinckrodt, Athlone, Ireland) and the cuff pressure controller regarding the prevention of pulmonary aspiration during mechanical ventilation. In fact, the LoTrach tube and the cuff pressure controller are designed to offer triple protection against pulmonary aspiration: The low-volume, low-pressure cuff without folds offering effective tracheal seal at permanent tracheal wall pressure between 20 and 30 cm H2O; the triple subglottic ports for intermittent suctioning of secretions and retrograde cleansing of the entire upper airway by irrigation with normal saline; and the nonstick inner lumen designed for reduction of adhesion of biologic material and biofilm formation. We believe that the LoTrachTM tube and the cuff pressure controller will contribute substantially to VAP prevention. However, there are still limited data about the clinical impact of the use of the LoTrachTM tube on the incidence of VAP, and further clinical research is required. Ioannis A. Pneumatikos, M.D., Ph.D., F.C.C.P.,* Christos K. Dragoumanis, M.D., Ph.D., Demosthenes E. Bouros, M.D., Ph.D., F.C.C.P. *University General Hospital of Alexandroupolis, Democritus University of Thrace, Medical School, Alexandroupolis, Greece. [email protected]