In regard to the recently published article in CHEST by Afessa et al (May 2010),1 the association between silver-coated tracheal tubes and reduced mortality in patients who developed ventilator-associated pneumonia (VAP) was interesting. However, more intriguing and much more concerning was the observation that silver-coated tubes were associated with increased mortality in patients without VAP. This is particularly relevant given that in most institutions, the number of patients who do not develop VAP vastly outnumber those who do, implying that silver-coated tubes may result in an overall excess in deaths. This concern is borne out in the original North American Silver-Coated Endotracheal Tube (NASCENT) trial,2 in which mortality was higher in the group randomized to receive silver-coated endotracheal tubes (30.9% vs 27.3%, P = .08). Although this difference did not reach statistical significance, the strong trend raises significant concerns about the safety and overall benefits of the silver-coated endotracheal tube. Extrapolating the mortality figures published by Afessa et al1 to Harborview Medical Center in Seattle, Washington, it is estimated that routine use of the silver-coated endotracheal tube in our institution would result in an excess of 54 deaths per year. It would be helpful if the authors could comment on this concern and on the potential mechanism for increased mortality related to the silver-coated endotracheal tube.