Rapid diagnostic test for sleeping sickness.

n engl j med 368;11 nejm.org march 14, 2013 1069 thereby reduce the duration of mechanical ventilation. Many, but not all, of these strategies were mentioned in our article. We also agree with the suggestion to avoid benzodiazepines, as has been recommended in the recent Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit.5 Ñamendys-Silva and colleagues are correct about the original purpose of the APACHE II score. We do not agree, however, with their comment about preemptive noninvasive ventilation after extubation. As noted above, an extremely important distinction with the use of noninvasive ventilation after extubation is whether it is administered in a preemptive manner rather than a reactive manner. In the controversial study by Esteban et al.,1 noninvasive ventilation was not initiated before the development of postextubation respiratory distress. Accordingly, it is not appropriate to reference this article with regard to preemptive noninvasive ventilation. We agree with the comments of Ñamendys-Silva et al. regarding the value of noninvasive ventilation in patients with chronic hypercapnic respiratory failure and obesity. John F. McConville, M.D. John P. Kress, M.D.