To Suction or Not to Suction, Above the Cuff

van Saene et al. make several excellent microbiological, clinical, and methodological points regarding the randomized trial by Valles and colleagues (1), many of which are more appropriately addressed to the investigators of this trial. As regards their rhetorical question, although critical appraisal of research necessarily converges on study design and results, responsible interpretation cannot proceed without understanding of pathophysiology and grounding with clinical expertise (2). Since publication of the Valles trial (1) and our article, 3 and 5 yrs have passed, respectively. Two additional randomized trials have evaluated subglottic secretion drainage, further advancing our understanding of the influence of this mechanical approach to nosocomial pneumonia prevention.