Letter to the Editor: Optimal device for emergency intubation - a commentary on the complementary role of intubating laryngeal mask airway-video laryngoscope

Abstract

The randomized controlled trial by Aggarwal et al recently published in World Journal of Critical Care Medicine, compared the intubating laryngeal mask airway (ILMA) with the Camera Macintosh video laryngoscope (VL) for emergency intubation in critically ill adults. In this randomized cohort of 58 patients, the VL demonstrated a higher first-attempt success rate, shorter intubation time, and superior glottic visualization compared to the ILMA. However, the role of the ILMA in specific high-risk scenarios warrants continued consideration. Adverse events were comparable between the two devices. The VL appears preferable as the primary device for emergency airway management, while the ILMA serves as an effective rescue option. Additionally, the ILMA remains useful in cases of restricted mouth opening and difficult airway scenarios.

Key Words: Emergency airway management; Video laryngoscopy; Laryngeal masks; Intubation; Intratracheal; Critical illness; Cervical immobilization

Core Tip: In emergency airway management, video laryngoscopy (VL) consistently provides higher first-pass success rates and faster intubation when visualization is reliable. However, its effectiveness decreases significantly in contaminated airways or when neck movement must be minimized. In these situations, the intubating laryngeal mask airway (ILMA) remains a valuable complementary device, allowing continued oxygenation, minimal cervical manipulation, and reliable intubation even without visual guidance. Rather than considering VL universally superior, clinicians should integrate both devices into airway management strategies-selecting VL for clear, stable conditions and ILMA for unstable, hypoxic, immobilized, or contaminated airways.

TO THE EDITOR

The randomized controlled trial by Aggarwal et al[1] recently published in World Journal of Critical Care Medicine, compared the intubating laryngeal mask airway (ILMA) with the Camera Macintosh video laryngoscope (VL) for emergency intubation in critically ill adults. In emergency airway management, device selection often prioritizes immediate success over theoretical advantages. It has been demonstrated that VL achieves rapid first-pass success and prevents esophageal intubation when the view is clear[2-5]. This evidence has understandably positioned VL at the forefront of most airway management algorithms. Here, we summarize key considerations to guide device selection in emergency settings. A summary of critical outcomes-first-pass success, total intubation time, complication rates, and suitability for difficult airways-is presented in Table 1 below.

Table 1 Comparison of intubating laryngeal mask airway vs video laryngoscope for emergency intubation.

Parameter	Intubating laryngeal mask airway	Video laryngoscope
First-attempt success rate	Moderate; improves with operator experience. Some studies, including those on manikins and humans, show lower first-pass success rates with video laryngoscopes[2,6,7]	Generally, there is a higher first-attempt success rate, consistently superior in comparative studies involving both manikins and humans[2-5]
Overall intubation success	High success rates are observed when fiberoptic assistance is used or multiple attempts are allowed[6-8]	Very high; strong evidence indicates improved overall success compared to the intubating laryngeal mask airway and direct laryngoscope[3-5]
Time to intubation	The procedure takes longer due to device insertion and tube advancement[2,6]	Shorter, particularly when good glottic visualization is achieved[2,3,8]
Restricted cervical spine mobility/trauma cases	Advantageous because it requires minimal neck movement and is effective even with manual in-line stabilization[6]	Effective but may still require some alignment; performance depends on the model[3,5]
Airway visualization	Blind unless fiberoptic used[7,9]	Excellent real-time visualization, particularly for challenging glottic views[3,4,9]
Usefulness in contaminated airway (blood/vomit)	More reliable because visualization is not required[6,7]	Visualization may be impaired by secretions, fogging, or blood[3,4]
Oxygenation during intubation	Possible continuous oxygenation and ventilation via the intubating laryngeal mask airway conduit[6,7]	Limited ability to oxygenate during intubation[3]
Ease of insertion	Simple insertion; however, there is a steep learning curve for blind intubation[6,7]	Moderately easy, but requires familiarity with video screen operation and angulation[3,5]
Complication rate	Lower dental trauma; occasional sore throat or epiglottic downfolding[6,7]	Possible mucosal injury, dental trauma, or soft tissue compression may occur[3,5]
Performance in obese patients	Effective; however, multiple attempts may be required[8]	High success rates and clear visualization have been demonstrated even in obese patients; airtraq and Camera Macintosh devices were studied[8]
Role in failed intubation	An excellent rescue device that facilitates oxygenation and intubation through a conduit[6,7]	Useful but not always ideal for rescue if visualization is obscured[3,4]
Ideal use scenario	Difficult airway, cervical immobilization, and failed laryngoscopy[6,7]	Emergency airway management requires the highest first-pass success rate[3-5]

The difficulty arises when the airway is obstructed. Blood or vomitus on the camera can transform an excellent VL view into nothing more than a red smear, causing performance to decline sharply[3,4]. In such situations, the ILMA tends to remain effective because tube placement does not depend on the operator’s visual field[6,7]. This practical consideration is frequently noted in clinical reports; however, guideline language continues to treat contaminated airways as a minor issue.

Cervical spine immobilization further underscores the importance of selecting devices on an individual basis. Although earlier concerns suggested that restricted neck movement might impair VL performance, recent evidence-including the study by Tienpratarn et al[2], conducted on manikins-demonstrates that VL can provide reliable glottic views during manual in-line stabilization. Additionally, the ILMA has consistently proven effective in this context, particularly when minimal cervical manipulation and uninterrupted oxygenation are priorities[6,7]. Rather than universally favoring one device, these findings support situational judgment.

VL can certainly be faster in controlled settings[2,5]. However, unfamiliarity with a specific blade or channel design often slows intubation. This variability is particularly evident in obese patients: Some channeled VL devices perform very well, yet the ILMA still achieves intubation even when the airway path is not straightforward[8].

CONCLUSION

For these reasons, promoting a single-device hierarchy appears unhelpful. VL is an excellent first-line option when visualization is reliable, but ILMA remains a dependable alternative when conditions are unstable, neck movement must be avoided, or oxygenation cannot be interrupted. Emergency airway guidelines would be more effective if they acknowledged this complementarity rather than implying the universal superiority of VL.