To the Editors:

I am writing in regards to the article “Suctioning Techniques and Airway Management Practices: Pilot Study and Instrument Evaluation” (July 2002:363–368). As the author suggests, healthcare personnel may be able to decrease the occurrence of ventilator-associated pneumonia by implementing a variety of strategies, including meticulous oral care, thereby reducing the effects of aspiration of oral-pharyngeal secretions laden with bacteria. Of concern, however, is the misconception regarding the management of cuffs on endotracheal tubes and their perceived role in preventing aspiration.

Aspiration is generally considered to have taken place when material penetrates the larynx and enters the airway below the level of the true vocal folds, the last line of defense in the upper airway. The endotracheal tube, therefore, by its very placement, maintains the true vocal folds in an abducted position, allowing for constant microaspiration of oral-pharyngeal secretions that pool and stagnate above the cuff. While suctioning...

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