Re-evaluate the downgrade of subglottic secretion drainage in VAP prevention guidelines: a call for evidence-based transparency

the Infectious Diseases Society of America (IDSA), and the Association for Professionals in Infection Control and Epidemiology (APIC), and their decision to downgrade subglottic secretion drainage (SSD) endotracheal tubes (ETTs) from "Essential" to "Moderate." 1 This letter builds upon previous discourse, such as the letter by Lichtenthal, 2 by introducing new evidence and highlighting further inconsistencies.I respectfully urge the authors to reconsider this decision, as it appears inconsistent with the existing evidence base and recent developments, having neglected to consider other excellent evidence-based and reliable published studies in their evaluation.Since the last guidance in 2014, numerous meta-analyses have consistently affirmed SSD's efficacy in reducing ventilator-associated pneumonia (VAP) incidence.Studies by Caroff et al. 3 and Carrascosa et al. 4 all conclude that SSD significantly reduces VAP.Although these meta-analyses consistently report that SSD's impact on mortality is not statistically significant, this outcome is a known challenge for VAP prevention studies.As noted by Caroff et al., 3 achieving statistical significance for mortality in VAP prevention trials would require sample sizes of many thousands of patients.The consistent reduction in VAP incidence itself, however, remains clear.Furthermore, as the late critical care luminary Luciano Gattinoni argued, relying on mortality as the sole primary end point is an insufficient measure of an intervention's effectiveness, especially for interventions that improve patient-centered outcomes without a direct impact on survival.This physiological-first perspective, published in JAMA 5 underscores why focusing exclusively on mortality can be misleading and can overlook important patient benefits like reduced organ dysfunction and shorter ICU stays.It is strikingly inconsistent that for the 2022 guidance, the authors primarily referenced the corrected Carrascosa et al. 4 paper to justify the downgrade, despite its conclusions on VAP incidence being consistent with Caroff et al., 3 a paper with shared authorship.This selective focus, given the broad body of evidence, warrants clarification.Furthermore, a profound inconsistency exists within the broader institutional commitment to SSD.The Agency for Healthcare Research and Quality (AHRQ), in its "Making Healthcare Safer"