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Bekele Afessa, MD, FCCP; Antonio R. Anzueto, MD, FCCP; Donald E. Craven, MD; Marin H. Kollef, MD, FCCP
Author and Funding Information

From the Mayo Clinic College of Medicine (Dr Afessa); Audie L. Murphy Division (Dr Anzueto), South Texas Veterans Health Care System; University Hospital (Dr Anzueto), University of Texas Health Science Center at San Antonio; Lahey Clinic Medical Center (Dr Craven); Tufts University School of Medicine (Dr Craven); and Washington University School of Medicine (Dr Kollef).

Correspondence to: Bekele Afessa, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905-0001; e-mail: Afessa.bekele@mayo.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(5):1275. doi:10.1378/chest.10-1724
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To the Editor:

We thank Dr Deem for the opportunity to elaborate on the mortality imbalance in our retrospective cohort analysis1 of the North American Silver-Coated Endotracheal Tube (NASCENT) study.2 The increased mortality among patients without ventilator-associated pneumonia who received the silver-coated endotracheal tube was unexpected in view of the lack of toxicity in NASCENT2 and previous studies3,4 comparing silver-coated with uncoated tubes. In a randomized, double-blind study of 11 healthy adult dogs,3 no evidence of toxicity was found on histologic examination after 96 h of mechanical ventilation. In a randomized phase 2 study of adults on mechanical ventilation,4 adverse events, including those unrelated to device or procedure, occurred in 47 (63%) of 75 patients in the silver group and in 46 (62%) of 74 patients in the control group. In the NASCENT study,2 adverse events possibly related to the device occurred in 122 (12.6%) of 968 patients in the silver group and in 111 (11.5%) of 964 in the control group (P = .46); corresponding numbers for adverse events definitely related to the device were 18 (1.9%) and 27 (2.8%) (P = .17).

To further evaluate the mortality imbalance in the NASCENT study,2 we examined all patients and found no between-group differences in hepatic failure, multiorgan failure, or other causes of death suggestive of silver toxicity. The only between-group difference in leading causes of death was respiratory failure, which occurred in 45 (19%) of 233 patients in the silver group and in 22 (11%) of 198 patients in the control group (P = .02). Collectively, these findings suggest that the mortality imbalance in the NASCENT study2 was more likely to be attributable to risk factors not captured in the case report form than to the silver-coated endotracheal tube.

Afessa B, Shorr AF, Anzueto AR, Craven DE, Schinner R, Kollef MH. Association between a silver-coated endotracheal tube and reduced mortality in patients with ventilator-associated pneumonia. Chest. 2010;1375:1015-1021. [CrossRef] [PubMed]
 
Kollef MH, Afessa B, Anzueto A, et al; NASCENT Investigation Group NASCENT Investigation Group Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;3007:805-813. [CrossRef] [PubMed]
 
Olson ME, Harmon BG, Kollef MH. Silver-coated endotracheal tubes associated with reduced bacterial burden in the lungs of mechanically ventilated dogs. Chest. 2002;1213:863-870. [CrossRef] [PubMed]
 
Rello J, Kollef M, Diaz E, et al. Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study. Crit Care Med. 2006;3411:2766-2772. [CrossRef] [PubMed]
 

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References

Afessa B, Shorr AF, Anzueto AR, Craven DE, Schinner R, Kollef MH. Association between a silver-coated endotracheal tube and reduced mortality in patients with ventilator-associated pneumonia. Chest. 2010;1375:1015-1021. [CrossRef] [PubMed]
 
Kollef MH, Afessa B, Anzueto A, et al; NASCENT Investigation Group NASCENT Investigation Group Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;3007:805-813. [CrossRef] [PubMed]
 
Olson ME, Harmon BG, Kollef MH. Silver-coated endotracheal tubes associated with reduced bacterial burden in the lungs of mechanically ventilated dogs. Chest. 2002;1213:863-870. [CrossRef] [PubMed]
 
Rello J, Kollef M, Diaz E, et al. Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study. Crit Care Med. 2006;3411:2766-2772. [CrossRef] [PubMed]
 
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