To the Editor,
We read the article Ajith et al. [1] with great interest. Airway management is a key skill in an emergency medical service setting. Until now, the gold standard of airway protection was endotracheal intubation based on direct laryngoscopy, which was dictated by the wide availability of laryngoscopes with Miller or Macintosh blades. It is worth bearing in mind that direct laryngoscopy is a specialist procedure that requires both knowledge and experience from the person performing it. However, there are many alternatives to direct laryngoscopy, including video laryngoscopy [2], vision tubes [3], and supraglottic ventilation devices (SADs) [4]. However, the first of the two alternatives are relatively expensive and rarely found in EMS teams. The situation is different with the SADs that are used by emergency medical emergency teams. In the current COVID-19 pandemic - where each patient should be treated as potentially infectious - bending over the patient's airways should be avoided - and the endotracheal intubation procedure itself is considered as an aerosol-generating procedure [5]. Therefore, it is reasonable to look for an alternative to direct laryngoscopy. As shown by many studies, “blind intubation” using supraglottic ventilation devices as a guide for the endotracheal tube may solve the problem. As pointed out by Ladny et al., for blind intubation, both laryngeal mask airway and iGEL masks can be used [6]. It is worth emphasizing that this method also works well during cardiopulmonary resuscitation of the patient. However, the research with the use of personal protective suits, which will verify the results obtained by other researchers, is of key importance. Blind intubation using SADs at the time of the COVID-19 pandemic may be a suitable alternative to direct laryngoscopy performed in EMS conditions.
References
- 1.Ajith P., Bandyopadhyay A., Meena S.C., Jain K., Aggarwal S., Gupta S.K. Direct laryngoscope versus McGRATH video-laryngoscope for tracheal intubation in trauma emergency: a randomized control trial. Am J Emerg Med. 2021;(21) doi: 10.1016/j.ajem.2021.09.042. 00779–8. S0735-6757. [DOI] [PubMed] [Google Scholar]
- 2.Szarpak L., Truszewski Z., Czyzewski L., Gaszynski T., Rodríguez-Núñez A. A comparison of the McGrath-MAC and Macintosh laryngoscopes for child tracheal intubation during resuscitation by paramedics. A randomized, crossover, manikin study. Am J Emerg Med. 2016;34(8):1338–1341. doi: 10.1016/j.ajem.2015.11.060. [DOI] [PubMed] [Google Scholar]
- 3.Truszewski Z., Szarpak Ł., Smereka J., et al. Comparison of the VivaSight single lumen endotracheal tube and the Macintosh laryngoscope for emergency intubation by experienced paramedics in a standardized airway manikin with restricted access: a randomized, crossover trial. Am J Emerg Med. 2016;34(5):929–930. doi: 10.1016/j.ajem.2016.02.054. [DOI] [PubMed] [Google Scholar]
- 4.Cereceda-Sánchez F.J., Clar-Terradas J., Moros-Albert R., Mascaró-Galmés A., Navarro-Miró M., Molina-Mula J. I-gel® laryngeal mask versus bag-valve-mask in instrumental cardiopulmonary resuscitation under capnographic monitoring: cluster-randomized pilot clinical trial. Aten Primaria. 2021;53(9):102062. doi: 10.1016/j.aprim.2021.102062. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Smereka J., Szarpak L. COVID 19 a challenge for emergency medicine and every health care professional. Am J Emerg Med. 2020;38(10):2232–2233. doi: 10.1016/j.ajem.2020.03.038. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ladny J.R., Bielski K., Szarpak L., et al. Are nurses able to perform blind intubation? Randomized comparison of I-gel and laryngeal mask airway. Am J Emerg Med. 2017;35(5):786–787. doi: 10.1016/j.ajem.2016.11.046. [DOI] [PubMed] [Google Scholar]