We thank Drs. Berra and Kolobow and Drs. Sathishkumar and Fassl for their interest in our review.1 

Berra and Kolobow raise the interesting question about the role of the patient position in the development of ventilator-associated pneumonia (VAP), and argue that keeping the orientation of the endotracheal tube below horizontal is the sole factor that can avoid VAP in intubated patients.

First, our review focuses on the pathogenesis and the preventive strategies of VAP, emphasizing the importance of endotracheal tube, hence we do not mentioned the role of patient positioning and its impact on VAP.1Second, 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,2–4a randomized controlled trial with 60 ventilated infants that compared the tracheal colonization rate and not the VAP incidence in supine versus  lateral position,5and unpublished observations in adult patients.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.6 

Drs. Sathishkumar and Fassl report the advantages of the LoTrach™ 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 LoTrach™ 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 LoTrach™ tube on the incidence of VAP, and further clinical research is required.7 

*University General Hospital of Alexandroupolis, Democritus University of Thrace, Medical School, Alexandroupolis, Greece. ipnevmat@med.duth.gr

1.
Pneumatikos IA, Dragoumanis CK, Bouros DE: Ventilator-associated pneumonia or endotracheal tube-associated pneumonia? An approach to the pathogenesis and preventive strategies emphasizing the importance of endotracheal tube. Anesthesiology 2009; 110:673–80
2.
Berra L, Curto F, Li Bassi G, Laquerriere P, Baccarelli A, Kolobow T: Antibacterial-coated tracheal tubes cleaned with the Mucus Shaver: A novel method to retain long-term bactericidal activity of coated tracheal tubes. Intensive Care Med 2006; 32:888–93
3.
Panigada M, Berra L, Greco G, Stylianou M, Kolobow T: Bacterial colonization of the respiratory tract following tracheal intubation-effect of gravity: An experimental study. Crit Care Med 2003; 31:729–37
4.
Bassi GL, Zanella A, Cressoni M, Stylianou M, Kolobow T: Following tracheal intubation, mucus flow is reversed in the semirecumbent position: Possible role in the pathogenesis of ventilator-associated pneumonia. Crit Care Med 2008; 36:518–25
5.
Aly H, Badawy M, El-Kholy A, Nabil R, Mohamed A: Randomized, controlled trial on tracheal colonization of ventilated infants: Can gravity prevent ventilator-associated pneumonia? Pediatrics 2008; 122:770–4
6.
American Thoracic Society, Infectious Diseases Society of America: Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416
American Thoracic Society, Infectious Diseases Society of America
7.
Young PJ, Pakeerathan S, Blunt MC, Subramanya S: A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med 2006; 34:632–9