Letter to the Editor: Insight into emergency endotracheal intubation in critically ill and strategies beyond equipment

Abstract

We read the study by Aggarwal et al recently published in World Journal of Critical Care Medicine, assessing the emergency endotracheal intubation (ETI) using two different equipment in critically ill patients and applaud it for choosing a crucial aspect of acute care. ETI remains a high-risk procedure in such patients with significant morbidity. The randomized design and objective outcome measures are notable strengths. Further, the inclusion of operator experience and contextual details enhances understanding of human factors and system-level influences. However, a few aspects warrant further consideration and discussion while adopting the research in clinical practice and future research.

Key Words: Emergency airway management; Critically ill; Intensive care unit; Preoxygenation; Adverse outcomes; Human factor

Core Tip: Emergency intubation outcomes in the critically ill depend not only on devices, but also on physiology, preparation, and systems. Recent literature highlights that attention to operator expertise and system-level factors in emergency endotracheal intubation addresses a critical aspect of acute care. Such practice and research therefore, require standardized reporting, pre-intubation optimization, and evidence-based protocols to enhance safety and generalizability across settings.

TO THE EDITOR

We read the study by Aggarwal et al[1] recently published in World Journal of Critical Care Medicine, assessing the emergency endotracheal intubation (ETI) using two different equipment in critically ill patients and applaud it for choosing a crucial aspect of acute care. ETI remains a high-risk procedure in such patients with significant morbidity. The randomized design and objective outcome measures are notable strengths. Further, the inclusion of operator experience and contextual details enhances understanding of human factors and system-level influences. However, a few aspects warrant further consideration and discussion while adopting the research in clinical practice and future research.

Firstly, although the study was designed to have acceptable power for time and may even be so for a first pass, confounding factors such as baseline severity of illness, pre-intubation oxygenation strategies, acid-base status, vasopressor use, and the urgency of intubation might introduce bias and limitations[2,3]. Additionally, standardized airway assessment or difficult airway risk scores might have provided a ground for direct comparison with recent literature. Readers and clinicians will benefit if such data are made available.

Secondly, pre-intubation optimization is an important aspect that needs attention in such cases. Current evidence and guidelines recommend pre-oxygenation with positive pressure in high-risk patients; non-invasive ventilation or high-flow nasal oxygenation can be used for the same[4,5]. Similarly, anticipation of hemodynamic collapse, preparation with pre-loading, and early vasopressor initiation as a mitigation tool are essential[4,5]. We believe that detailed reporting on these measures will help interpret outcomes or comparisons across centers and researchers. Additionally, timing data such as the interval from ICU admission to intubation or the progression of respiratory failure would strengthen future studies and bolster risk stratification.

Lastly, equipment selection, particularly in settings where physiological instability and time-sensitive decision-making directly influence outcomes, should be evidence-based[3]. Aggarwal et al[1] reaffirm Tienpratarn et al[6] earlier findings about the first pass efficacy and less time requirement to secure airway using video laryngoscopes (VLs) in real-world practice. However, comparing equipment classes that are functionally dissimilar, such as VLs vs supraglottic airway devices, may limit generalizability, especially when the authors used the intubating laryngeal mask airway (ILMA) as a conduit only for ETI. Notably, ILMA often requires external maneuvers to achieve proper alignment with the laryngeal inlet and is better suited to a silicone-made, reinforced, flexible endotracheal tube (ET) designed for it. While it is undeniable that standard polyvinyl chloride (PVC) ET also provides a good first-pass success, and the authors’ use of pre-warmed PVC ET is pragmatic, it might affect trauma-related outcomes, external maneuvering, and time.

Despite these limitations, Aggarwal et al[1] study provides meaningful new insights into the risks associated with emergency ETI in the critically ill and the choice of airway management device. Nevertheless, the findings highlight opportunities for improvement through evidence-based airway management strategies and system-oriented interventions. Incorporating physiological guidance into intubation protocols, promoting clear team roles, and using standardized checklists might further improve outcomes. Thus, future research on human and system-level factors beyond airway equipment is essential.