End-of-life treatment and antibiotic resistance data raise questions.

www.chestpubs.org First, it is surprising that signifi cant differences in the evaluated outcomes are found in studies with such small sample sizes ( , 70 patients per study in all studies). Second, all the studies except the trial by Trevisan et al 6 were carried out in respiratory units admitting mostly patients with COPD. This is not the rule in most ICUs. 7 Third, the control groups (invasive weaning) in these studies do not refl ect current clinical practice. For instance, in the study most favorable to NIPPV, 5 outcomes in patients assigned to invasive weaning were: rate of nosocomial pneumonia, 59%; rate of reintubation, 21%; need for tracheostomy, 59%; and ICU mortality, 41%. To try to compare those data with the real world, we have searched in the databases of two international studies on mechanical ventilation. 7 In these databases, we have selected patients with COPD who required mechanical ventilation for . 3 days and had a duration of weaning . 3 days. This patient population would be similar to that in the study by Ferrer et al. 5 From a total cohort of 10,151 patients who were mechanically ventilated, we found 160 patients meeting the above-mentioned criteria. The outcomes of this cohort were: rate of nosocomial pneu monia, 7%; rate of reintubation, 21%; need for tracheostomy, 9%; and ICU mortality, 10% (data not previously published). Last, the withdrawal of the endotracheal tube for patients failing a spontaneous breathing trial could raise ethical issues.