Peri-operative medication safety is complex. Avoidance of medication errors is both system- and practitioner-based, and many departments within the hospital contribute to safe and effective systems. For the individual anaesthetist, drawing up, labelling and then the correct administration of medications are key components in a patient's peri-operative journey. These guidelines aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors. The aim is that they will be used as a basis for instilling good practice.

We thank Drs Dob and Norman for their comments [1] on our editorial [2] but we think they may have conflated several different issues in relation to tracheal tube placement. We had hoped an earlier article would have clarified and so pre-empted the sort of queries they raise [3]. They seem to imply that with oesophageal intubation there is “difficulty with ventilation”, which they define as being accompanied with high inflation pressure. This is not always the case. Dob and Norman are correct to imply that complete obstruction of the tracheal tube or circuit can lead to a scenario of ‘no trace, correct place’. This is apparently counter to the slogan being promoted by the Royal College of Anaesthetists: ‘no trace, wrong place’. However, the propositional logic around these two statements, both equally true, was addressed in a recent article [3]. Finally, Dob and Norman propose checking correct tube position by passing a suction catheter to “aspirate gastric contents”. We are unsure of how they know this aspirate is ‘gastric’? Presumably, the implication is pH testing; yet this is unreliable [4], which is why the latest Healthcare Safety Investigation Branch report has criticised this method [5]. Moreover, what if no aspirate is obtained? The latest Association of Anaesthetists’ guidelines for minimum monitoring now recommend the immediate availability of a fibreoptic scope, and this supersedes the older, blind methods Dob and Normal advocate in confirming correct tracheal tube placement [6]. In summary, we think Dob and Norman may have conflated the problems of ‘no trace’ with ‘difficult (i.e. high inflation pressure) ventilation’ and also with ‘worsening desaturation’. These to us seem very different things, albeit at times related, but to regard them as equivalent seems unhelpful. J. J. Pandit OxfordUniversity Hospitals NHS Foundation Trust, Oxford, UK Email: jaideep.pandit@dpag.ox.ac.uk P. J. Young Queen Elizabeth Hospital, Kings Lynn, UK M.Davies PeterboroughCity Hospital, Peterborough, UK

Contemporary guidance takes a patient-centred approach and recommends discussing and planning treatments that should be considered, not just those that should be withheld. Although some organisations and communities still use specific DNACPR (do not attempt cardiopulmonary resuscitation) forms to recommend that cardiopulmonary resuscitation is not attempted, this approach has been shown to have disadvantages and is no longer regarded as best practice. The following guidelines have been produced in response to this change. They are designed to help anaesthetists, as part of the wider healthcare team, to implement and respond to advance care planning documents before and during procedures. The guidelines apply to all procedures, however minor and low risk they are considered to be, and the same ethical and legal principles apply to procedures carried out under local or regional anaesthesia and/or conscious sedation, as well as to those under general anaesthesia.

We thank Dr Kelly and Professor Cook for their helpful comments [1], which add important detail to our editorial [2]. There is perhaps a slight difference in emphasis as we see the fundamental issue as being to confirm correct placement and not just detect oesophageal placement. Their proposal for capnographdisplay is not incompatible with our suggestion for an ‘intelligent’ audible alarm to alert the operator, but we do not agree that the display alone (without audible alarm) will be useful. We agree that videolaryngoscopy (with screen technology) should be universal, that is used by default. We sincerely hope that, together with Kelly, Cook and other colleagues, we can make this idea of universal videolaryngoscopy the norm in the literature. User familiarity apart (which we hope will be addressed by training), there now needs to be a specific indication for using direct (Macintosh) laryngoscopy, but we cannot imagine at present what that specific indicationmight be. We support Kelly and Cook’s comments on mandatory training. This should, however, be more than a tick-box exercise that so much mandatory training within the NHS appears to have become [3]. Coupled with training should be education (the reading, discussing and understanding of the wider literature) [4]. The frank admission to the coroner by a clinical director in the unit where the index tragedy occurred, that there was no awareness of ‘no trace, wrong place’, suggests there is much more to be done by all anaesthesia organisations in this regard. Finally, Kelly and Cook appear to suggest that, because clinical assessment cannot confirm correct positioning, it should be abandoned altogether. We caution against this. (It would be akin to suggesting cardiologists abandon the stethoscope, simply because echocardiography now supersedes it.) Clinical examination is, or ought to be, part of a ritual that culminates in checking the capnograph and verbalising the result. It is also essential because, as discussed elsewhere, ‘no trace, wrong place’ does not mean ‘positive trace, correct place’ [5]. There are many life-threatening scenarios where, despite a positive carbon dioxide trace, the tube ismisplaced and this requires clinical assessment.

AnaesthesiaEarly View Correspondence Preventing gastric insufflation when facemask ventilation is applied during high-flow nasal oxygenation P. J. Young, Corresponding Author P. J. Young peteryoung101@googlemail.com Queen Elizabeth Hospital, King's Lynn, UKSearch for more papers by this author P. J. Young, Corresponding Author P. J. Young peteryoung101@googlemail.com Queen Elizabeth Hospital, King's Lynn, UKSearch for more papers by this author First published: 02 March 2022 https://doi.org/10.1111/anae.15701 PY has received speaker fees and sponsorship from Fisher and Paykel Healthcare which has developed a similar device. No other competing interests declared. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

© Author(s) (or their employer(s)) 2021. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. INTRODUCTION Medication stored in hospitals, nursing homes, general practice surgeries or pharmacies must be handled, stored, dispensed and disposed of securely to protect patients and staff in accordance with part 4, section 13 of the Health and Social Care Act. These standards were revised in 2014, requiring the service provider to ensure ‘proper and safe management of medicines’. The Care and Quality Commission (CQC) regulates compliance with this legislation by performing routine inspections of health and social care providers. In hospitals, controlled drugs (CDs) such as sedative or opiatebased medications are stored within locked cupboards. Both CD cupboards and drug trolleys, when open, must be constantly supervised by staff and if left unattended securely locked, even for short periods. In reality, guideline compliance in busy healthcare environments can be challenging to achieve. During planned CQC visits, staff may be at their most compliant, yet in 2012 inspectors reported that 14% of hospitals, 20% of nursing homes and 16% of residential homes across the UK failed to comply with the safe management of medicines standard during visits. Unlocked unattended medication trolleys have specifically been highlighted as issues of poor medication management in CQC reports, and in some cases this has affected care ratings of institutions and led to enforcement actions. 7 Ultimately, failure of adherence to CQC recommendations can result in medication theft and tampering for which healthcare staff, who have easy access to drug cabinets, are often found to be culprits; and this is highlighted in disciplinary hearings for the General Medical Council and Nursing and Midwifery Council. An anaesthetist sentenced to jail illustrates this, who used his old hospital pass to access and steal 2558 tablets of codeine from hospital cabinets, with costs totalling £3360. This occurred over 8 months with 75 different visits to the hospital, highlighting the ease with which recurrent theft may occur and the vulnerabilities of healthcare systems to medication diversion. Drug diversion is defined as the transfer of drugs from a lawful to an unlawful channel of distribution or use. This may only be the tip of the iceberg and there are likely many more incidents dealt with internally or remaining undetected. Summary box

In order to reduce transmission of the SARS-CoV-2 virus, healthcare workers in the UK are advised to wear personal protective equipment (PPE). When undertaking aerosol generating procedures, Public Health England recommends the use of gloves, gown, filtering mask and full-face visor or goggles 1. Despite this, uncertainty remains regarding the role of some items of PPE, such as hoods and visors 2. In an institution in Wuhan, in the early stages of the COVID-19 outbreak, 29% of all infections were among healthcare workers 3. Following doffing and within 'clean' zones, healthcare workers touch their faces every few minutes, with approximately half of these episodes involving contact with mucous membranes, rendering facial skin contamination a significant portal of entry for respiratory viruses 4. A volunteer, one of the authors, gave written consent to participate in a study to determine the effectiveness of PPE. A brown cornstarch-based colloidal solution (Bisto®, Premier Foods, St Albans, UK) was sprayed at an arm's length from the volunteer wearing three levels of PPE including that recommended by Public Health England, simulating droplet spray: test 1: hat, goggles, mask and gown; test 2: hat, goggles, mask, gown and visor; and test 3: high-necked full-body suit and full-face visor. Figure 1a–c shows adherence to the Public Health England PPE guidance with theatre hat, goggles and filtering mask results in substantial areas of contamination from droplet spray; in particular, the forehead, bridge of nose, cheeks and neck. Figure 1d shows that the addition of a full-face visor still leaves the neck exposed. Figure 2 shows that a high-necked full-body suit and full-face visor eliminated droplet skin contamination in this model. Our study demonstrated that, despite complying with Public Health England guidance, healthcare workers remain vulnerable to droplet contamination of exposed skin. To reduce droplet-associated transmission of SARS-CoV-2 from exposed skin, healthcare workers require additional neck, face and hair protection such as a high-neck hooded overall suit and full-face visor.

Anaesthetists have a strong history in innovation with translation to patient benefit on a worldwide scale. In the mid-nineteenth century, at the birth of inhalational anaesthesia, many clinicians across the world developed devices to administer ether by combining an understanding of the problem, the clinical environment and by application of the latest science and technological abilities of the time. Some took out patents, many devices failed and all were superseded with improvements over time 1. Some innovations are so simple yet revolutionary that they have stood the test of time and technological advancements. The development of the Macintosh laryngoscope blade in the 1940s is well documented 2, 3. Macintosh observed the excellent view created by the short curve of the Boyle–Davis gag during tonsillectomy and within the day had this blade soldered onto a laryngoscope handle by his assistant. Macintosh never patented this in the UK and his assistant began selling homemade devices to visitors at the hospital; subsequently multiple companies produced these as popularity spread. Collaboration with manufacturers in the USA identified a number of patentable improvements. In 1981, Archie Brain developed his laryngeal mask airway, and crucially made strategic clinical and business alliances to springboard this into ubiquitous practice 4. All of these inventions began with practising clinicians solving problems in an iterative way and required their clinical drive and resilience to gain support from industry and professional colleagues and the will and ability of frontline clinicians and managers to adopt and implement. These inventions benefited patients by improving care and safety, but crucially for adoption, also made the life of the user much easier. The innovation pathway is sequential. It begins with a simple idea and concludes with timely implementation, the latter perhaps the most challenging stage. The clinician must be in a supportive environment to allow freedom and support to enable development of an idea. Fortunately, since ‘Innovation, Health and Wealth’ was published in 2011 5, clinical innovation and entrepreneurship has been encouraged from the highest levels of the Department of Health. This has resulted in the formation of: NHS Innovation Agencies who consider ideas coming from hospitals; the Clinical Entrepreneur Programme with a purpose to educate, assist and support clinical innovators; the NHS Innovation Accelerator programme which helps fund and facilitate the introduction of proven mature innovations into practice; and the Academic Health Science Networks which are poised to help at the implementation phase. The Association of Anaesthetists holds innovation sessions and awards at the annual Winter Scientific Meeting to promote, support and give an indication of approval for innovators and entrepreneur members to recognise, help and encourage them on their journey. Most ideas will have been thought of before and all will be building on previous concepts. If the idea hits a sweet spot and is solving a clinical problem at just the right time, then it is likely that overlapping intellectual property is being sought contemporaneously by like-minded clinicians and companies across the world. Capturing intellectual property is normally very important, not to make a quick profit which is sometimes a casual perception, but to encourage and allow manufacturers to make a business plan for the considerable investments needed upfront for development. Normally, only current market leaders with already well-developed influence and distribution networks can tolerate investing in projects for non-protectable devices. Filing for intellectual property can be done in one country relatively easily and cheaply, but within a year the invention must have proven itself sufficiently to file patents around the world at considerable expense. The patent will cover only a narrowly defined part of the device. The inventive step must be novel, not an obvious improvement of prior art, and have utility. Normally as the years go by and a patent undergoes substantive examination by the Patent Office and challenges from competitors, the claims become narrower and the device will lose much of its protection. This is one reason why it is so hard to get engagement from industry to develop an idea. Sadly, the contracts signed by the vast majority of clinicians in the NHS refer to a national intellectual property (IP) document that claims ownership by the employing hospital Trust of the employee's ideas 6. This can be extremely problematic in non-enlightened Trusts, as if there is not tangible support and progress from the institution, the inventor may not have the freedom to negotiate an idea through an alternative pathway. Honorary contracts held by clinicians with other Trusts or universities will also have intellectual property clauses and it is likely that intellectual property has been accidently signed to multiple owners, creating the potential for personal liability. Ambiguity of intellectual property ownership can occur, and this can be challenging during negotiations of assignment to companies during the process of due diligence. The final step in the pathway is implementation. Normally, implementation is initially in a controlled market. This is due to manufacturing, supply chain, distribution, promotion and financial constraints, and also due to the fine-tuning and iteration of design that inevitably occurs when the device is exposed to disparate clinicians, patients and healthcare systems. It is said that this phase takes an average of 17 years in the NHS 7. This is much longer when compared with high-tech industries; for example, the iPhone (Apple, Cupertino, CA, USA) has undergone 10 releases in as many years. This is important as medium or smaller companies may fail to tolerate this financial hole as development costs vastly exceed income. This financial mismatch is known as the ‘valley of death’ 8 and sadly this is where many bed-side innovations disappear. Large medical companies, however, have the resources and expertise within their team for development and are strategically able to influence the adoption of medical devices in healthcare settings. This month in Anaesthesia, Darwood et al. 9 and Williams et al. 10 describe devices at the early stages of the innovation pathway undergoing development and early prototype testing. I applaud these clinicians for their imaginative solutions to clinical problems that challenge all anaesthetists, but in particular their tenacity to push forward their developments and desire and commitment to go further, perhaps against the odds. The syringe safety device by Williams et al. is an elegant solution to a problem that we have all experienced directly or with near-misses – that is, syringe substitution error. This is likely to be an under-reported problem. Vaso-active drugs such as ephedrine and metaraminol normally need to be available immediately to the anaesthetist to be injected in small aliquots. Currently, these drugs are presented in a standard syringe with labelling. All anaesthetists are susceptible to the normal psychological phenomenon known as inattention blindness and warning fatigue, especially at times of stress, distraction and when rapidity of administration is essential. The investigators test a solution that provides a strong visual feedback to the user in addition to a haptic feedback when the syringe is in use, allowing discrete 1-ml aliquots of drug to be given. A prototype has been 3D-printed and fine-tuned both during benchtop testing and by exposure to clinicians in a controlled way. My first observation was that the authors do not appear to have filed a patent. This rings alarm bells as it could become un-investable by all but the largest companies whom, with busy research and development programmes of their own, are notoriously difficult to engage with. Doing a patent search, which I assume the authors have also done, a number of interesting patents emerge. A patent from 1984 11 describes a syringe with a primary purpose to block ultraviolet rays. A dependent claim (i.e. it will only apply to ultraviolet blocking syringes) describes a plunger with circumferential grooves with a detent portion on the barrel engaging in the grooves giving a tactical and auditory indication of plunger position. This is of interest because this is a public, dated disclosure and the patent has now expired following its 20-year lifespan, meaning anyone can make a syringe with the elements as described in this patent. Also of note is a flurry of activity in this area, covered in part by patent classification section ‘Dosing by means of stepwise axial movements, e.g. ratchet mechanisms or detents.’ At the time of writing, there are 61 patents in this category 12. This year already, a number of patents have been filed with variations and improvements on the theme to give feedback for controlled or incremental injection 13, 14. So, will we see this most useful concept in our practice anytime soon? The answer is possibly. One of the world's leading syringe manufacturer filed patents in 2008, 2013 and 2017 on this theme. The earliest in 2008 15 describes a plunger with features connected to the barrel that interacts to provide for intermittent stops to the injection process and which divide the dose into discrete intervals. So, any manufacturer could make elements of these that will work. The market-leading syringe manufacturer above will do so if the will and business case exists and no one will be able to directly copy them for the lifetime of the patent, although variations will be possible if one avoids infringements of the 61 other patents identified above. It struck me that I would like access to the 3D printer code, produced by Williams et al. to print some for personal use and for others to do the same. Out with ethical, GCP and regulatory issues, I consulted a senior partner in a leading IP firm. In most jurisdictions, if I suggested this and it did infringe a patent, then I would be guilty of contributory infringement by the UK Act 16 which protects the against the following ‘makes, disposes of, offers to dispose of, uses, or imports’ and I and the user would be exposed to damages for lost sales. So, if we desire this in practice, our professional organisations, healthcare systems or through international standards would need to lobby industry to produce them and prospectively agree to accept the associated costs, and generate pull from the end-users. Notably, even with a very strong push from these and legal bodies, the non-Luer connector (NRFit, GEDSA, Columbus, OH, USA) implementation, which at first glance may look relatively simple, has taken decades to develop and implement. I suspect I will not be able to utilise this simple engineered safety device to protect my patients in my lifetime. The paper by Darwood et al. describes an elegant, simple, portable ventilator under development, which it is proposed could replace current portable ventilators which tend to be more complex and are costly. However, existing devices have been developed by experts in the field to provide options for even the most complex requirements. So is there a niche for a simplified device? If the business model allows this to be developed and distributed at a more economical cost and the design is lighter, more robust, convenient and maintenance is easier, then one can see the potential for application in developing countries and for field anaesthesia. Additionally, one can imagine this being used in secondary care for routine stabilisation and transfer for uncomplicated patients. The authors have filed a patent relating to aspects of function and it is currently at an early stage in its examination. Whether the particular patent protection that is ultimately achieved by Darwood is required for the development of a successful device is another question and only time will tell. One might imagine if such a device is attractive to clinicians and managers this might be a commercial threat to manufacturers of more complex portable ventilators. In my view, Darwood has two choices. One option is to attempt to make strategic alliances with established ventilator manufacturers who have the infrastructure for both development and facilitating implementation. My experience is that at this early stage, one's bargaining position is poor not only in terms of royalties (if sought) but more importantly also losing control over the direction of the development or even abandonment along the process. Additionally, the unique features described in a final granted patent may or may not be required in a final product. The expertise, tenacity, expectations and the likely longevity of engagement of the innovator may be just as important to a company deciding whether to engage. The second option is to achieve engagement with smaller companies or seek investment from venture capitalists or the like. The latter normally means a change in career for the clinical entrepreneur. Engagement is challenging as investors are well aware of the valley of death that they may be approaching as expenditure skyrockets and implementation falters. I wish both teams the best, and I ask clinicians reading this article to provide positive support and favourable discrimination for our clinician innovators who have formed, or are working with, smaller companies and traversing the valley of death in an attempt to engineer improvements into our practice. An increase in this activity will hopefully bring bed-side improvements to us in a timely manner and also encourage others to progress their ideas to drive our specialty forwards. PY is named as inventor on a number of patents in the field of mechanical ventilation and syringe technology. No external funding or competing interests declared.

Summary Arterial cannulation is associated with complications including bacterial contamination, accidental intra‐arterial injection and blood spillage. We performed a series of audits and experiments to gauge the potential for these, as well as assess the possible contribution of a new device, the Needle‐Free Arterial Non‐Injectable Connector ( NIC ), in reducing these risks. The NIC comprises a needle‐free connector that prevents blood spillage and a one‐way valve allowing aspiration only; once screwed onto the side port of a three‐way tap, the device can only be removed with difficulty. We performed a clinical audit of arterial monitoring systems in our intensive care unit, which showed an incidence of bacterial colonisation of five in 86 (6%) three‐way tap ports. We constructed a manikin simulation experiment of the management of acute bradycardia, in which trainee doctors were required to inject atropine intravenously. Ten of 15 (66%) doctors injected the drug into the three‐way tap of the arterial monitoring system rather than into the intravenous cannula or the central venous catheter. In a laboratory study, we replicated the arterial blood sampling and flushing sequence from a three‐way tap, with the syringes attached either directly to the three‐way tap port or to a NIC attached to the port. The first (discard) syringe attached to the three‐way tap was contaminated with bacteria. Bacterial growth was found in 17 of 20 (85%) downstream flushed samples (corresponding to the patient's circulation) when the three‐way tap was accessed directly, compared to none of 20 accessed via the NIC (p < 0.0001). Growth was found on all of 20 (100%) ports accessed directly compared to none of 20 accessed via the NIC (p < 0.0001). The NIC effectively prevents bacteria from contaminating sampling lines. As its design also prevents accidental intra‐arterial injection, we suggest that it can reduce complications of arterial monitoring.

CONTEXT:Laryngoscope handles are a potential vector for infection transmission and require adequate decontamination.OBJECTIVE:To establish an effective cleaning regimen for laryngoscope handles.DESIGN:Three laboratory studies and an audit cycle.SETTING:The Queen Elizabeth Hospital, King's Lynn, UK.MATERIALS:Twenty Heine laryngoscope handles.INTERVENTIONS:Twenty laryngoscope handles were contaminated with microbial broth and then disinfected with chemical wipes, either using Sani-Cloth CHG 2% (chlorhexidine 2%/alcohol 70%) or Tuffie 5 wipes. This was repeated with an interval of 24 h between cleaning and contamination. A further experiment repeatedly re-contaminated the handles at varying time intervals after cleaning. The audit established the current level of contamination of laryngoscope handles within the hospital, and this was repeated following a change in cleaning protocol.MAIN OUTCOME MEASURES:Bacterial growth on agar plates was counted as the number of colony forming units.RESULTS:Both Sani-Cloth CHG 2% and Tuffie 5 wipes were effective against microorganisms, including methicillin-resistant Staphylococcus aureus, immediately following wiping (P = 0.002). However, the chlorhexidine wipes also had a residual effect such that after wiping, the handle remained sterile following further contamination and this effect persisted for 24 h. Audit following the introduction of this practice showed significant improvements in the incidence and extent of contamination compared with the previous disinfection practice (P<0.002).CONCLUSION:Decontamination with Sani-Cloth CHG 2% wipes confers additional advantages over routine autoclaving or handle disposal, due to a residual effect. Autoclaving handles may be desirable on a scheduled basis and if Clostridium difficile is encountered.

Bougies are susceptible to becoming contaminated before or during use. Chlorhexidine wipes may have a residual antibacterial effect, potentially minimising bacterial transmission after bougie use or storage. We evaluated the decontaminant and antibacterial effectiveness of 70% alcohol/2% chlorhexidine wipes in laboratory, clinical and accelerated ageing studies, and conducted a telephone survey of normal practice. In the laboratory tests, chlorhexidine wipes were completely effective against Escherichia coli and methicillin-resistant Staphylococcus aureus, and prevented recontamination for 24 h. Clinical introduction of chlorhexidine wipes reduced bougie contamination from 33% to 0%. Following 150 cleaning episodes, there was no physical or functional damage to the bougies. Eight out of nine hospitals in the East of England Health Region use re-usable bougies. We recommend that following decontamination, bougies should be wiped with 70% alcohol/2% chlorhexidine wipes, to retain antimicrobial activity during handling.

INTERVENTIONS Twenty laryngoscope handles were contaminated with microbial broth and then disinfected with chemical wipes, either using Sani-Cloth CHG 2% (chlorhexidine 2%/alcohol 70%) or Tuffie 5 wipes. This was repeated with an interval of 24 h between cleaning and contamination. A further experiment repeatedly re-contaminated the handles at varying time intervals after cleaning. The audit established the current level of contamination of laryngoscope handles within the hospital, and this was repeated following a change in cleaning protocol.

Intra-arterial injection of drugs intended for intravenous delivery is a frequent and potentially devastating consequence of placing an arterial line in a patient. A system is described here that prevents this complication from occurring and its use is advocated in intensive care and operating theatre settings.

The pathogenesis of ventilator-associated pneumonia (VAP) is iatrogenic and multifactorial [1]. Many of the known risk factors relate to the presence of an endotracheal or tracheostomy tube which bypass many of the patient’s protective mechanisms and increase the chances of upper and lower airway colonization, aspiration, and infection [2]. The sequence of colonization of the aerodigestive tract, followed by the tracheal tube and then ventilator circuit has been elegantly described by Feldman [3]. This sequence begins with oropharyngeal colonization after 1–2 days, followed by colonization of the stomach, then the lower respiratory tract (2–4 days), and thereafter the endotracheal tube. A reflection of the importance of the artificial airway has led some authorities to refer to the condition as “tracheal tube-associated pneumonia” [4].