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Oral antiseptics, like semirecumbent positioning and care of the ventilator circuit, merely address the symptom and not the cause of ventilator associated pneumonia (VAP).1
The pivotal step in the pathogenesis of most cases is aspiration of secretions past the cuff of the tracheal tube.2 Aspiration occurs because of a design defect in almost all cuffs currently available, with leakage along folds in the cuff wall. Pepsin (a marker of gastric regurgitation and aspiration) is present in tracheobronchial secretions in 89% of patients at some stage during their stay in critical care and is the most important independent risk factor for developing VAP.3
Manufacturers are now beginning to improve the design of tracheal tubes, ensuring maximal cuff performance and incorporating subglottic secretion drainage ports and antibacterial/non-stick linings. Simply preventing the ubiquitous problem of pulmonary aspiration by cuff improvements may have a substantial impact on VAP and reduce the requirement for topical antiseptics or antibiotics.4 5
Competing interests: DLW has received one speaker fee from Venner Capital, the manufacturer of the LoTrach tracheal tube. PJY consults and has received educational and research support from Venner Capital.