Letter to the editor in response to “Prevention of skin injuries associated with non-invasive mechanical ventilation”

Dear Editor,

Valued Dr. Otero requested that the results of his study¹ be included in our publication.² As we specify in the methodology of our paper, it is a review of the bibliography which ended in August 2016, while his clinical trial was published 9 months later. Reviews are subject to the same factors as clinical practice guides, as after publication new diagnostic and treatment methods may emerge, so that it is necessary to make regular revisions.³ Due to this reason, reviews show clearly delimited time intervals that make it clear which papers may be selected.

It is true that his paper helps to generate high-quality evidence, given that it is based on a randomised clinical trial. However, GRADE⁴ methodology would have to be used to evaluate whether there are any distortions that may lower the quality score of the estimation of the effect of hyperoxygenated acids. These may include the non-concealment of the randomisation sequence, the lack of blindness, excessive losses during follow-up and the lack of analysis based on intention to treat, among others.

It is precisely because of the lack of clinical trials found in our review of the bibliography (only 5 of 30 papers, of which 3 were not randomised), as we pointed out in our paper, that it is impossible to use the GRADE⁴ methodology to formulate recommendations and procedures for expert consensus.

We understand that your contribution regarding the use hyperoxygenated fatty acids to prevent pressure/friction sores associated with non-invasive mechanical ventilation opens the door to new possibilities for prevention. Nevertheless, we disagree with the use of the scale of Norton et al.⁵ to stratify the risk of suffering pressure sores in critical patients, recommending Braden's scale.⁶ This is validated for this population and moreover, critical patients with a low score in the “friction and risk of lesions” sub-scale are at 2.5 times greater risk of suffering a lesion.⁷

We sure that in future reviews of lesions associated with clinical devices, as well as when preparing clinical practice guides connected with this subject, such as those by the EPUAP,⁸ your paper will be included and appreciated by the scientific community, so that it can be compared with the methods used to date.