A reply

Abstract

I thank Drs Lacquiere and Heard for their comments, agreeing with many of their points from the perspective of an anaesthetic service and acknowledge that our paper was published in an anaesthetic journal. However the study was conducted by emergency physicians and with the issues facing doctors in charge of emergency departments in mind, particularly after-hours when smaller departments may not have on-site anaesthetic services or the sole anaesthetic registrar may not be immediately available. I wholeheartedly agree that regular training in a range of emergency airway skills is optimal and should be the focus. This will be more achievable in an anaesthetic service than in an emergency medicine service. The practical issues around providing this training for emergency departments relates to the lesser number of emergency medicine specialists and trainees, with subsequent reliance on non-training staff, who require teaching across the entire spectrum of clinical medicine. There is also a high turnover of staff which adds to the complexity of maintaining a pool of appropriately trained staff. Oxygenation is the immediate goal in the CICV situation and cannulation with high flow oxygen delivery can accomplish this. We agree that this is rapid, easily achievable and should be instituted. It does not, however, achieve either adequate ventilation or airway protection (either of which may have been the reason for considering intubation in the first instance). Also, given that many of the devices tested could be inserted and have ventilation started in 40–60 s, the potential time gain is short. For emergency medicine staff in the situations outlined above there will frequently still be a need to provide a larger calibre, cuffed airway within a short timeframe. The transfer from needle oxygenation to a more secure, substantial airway is a potentially dangerous procedure under significant time pressure. Equipment that is more intuitively easy to use will reduce risks at this point. In terms of the model, we have discussed a number of the advantages and disadvantages of different available platforms in the paper. I do not have any additional comments to make in this regard.