Commentary, response to Benger

Abstract

Wewelcome Benger's comments following our article ‘Why do I intubate cardiac arrest victims?’ [1] regarding his belief that basic airway management may be superior to advanced airway management due to a lack of evidence for the latter. The evidence presented by Benger is reasonable and we accept the comments made around it. There is good quality evidence for uninterrupted cardiopulmonary resuscitation (CPR) and early defibrillation [2], both of which most emergency medical service (EMS) providers have frequent exposure to. The emphasis in many studies has been on completing the basic interventions consistently and to a consistently high standard. We do not advocate that endotracheal intubation is performed routinely by all EMS providers or indeed in all situations. Instead, we describe advanced airway management in the context of a highly-skilled team. There is reasonable evidence that paramedics have limited training and exposure to intubation [3]. However, several organisations have now published intubation and complication rates for advanced airway interventions with very high success rates [4,5]. Patients treated by these teams almost always undergo the basic levels of airway management described by Benger prior to the arrival of the specialist team. In the systems we describe, intubation is most often not the initial airway management strategy e most patients undergo the basic levels of airwaymanagement described by Benger prior to the arrival of the specialist team. When it is performed, intubation is part of a series of intensive care level interventions aimed at stabilising the patient. If a team is appropriately skilled and the right individuals are present, why would you not intubate a patient if it were required? We advocate this because we understand that definitive airway management eventually occurs in all patients with a successful return of spontaneous circulation (ROSC) prior to arrival in the intensive care unit. Supraglottic airway devices clearly have their place in the initial airway management of a range of pre-hospital patients, however they usually require changing at some point during an intensive care admission. Intubation in the pre-hospital