Advanced airway management in drowning: Pre-hospital tracheal intubation as compared to supraglottic airway device

To the Editor, We appreciate the efforts of Dr. Yoshimura et al1Yoshimura S. Kiguchi T. Nishioka N. et al.Association of pre-hospital tracheal intubation with outcomes after out-of-hospital cardiac arrest by drowning comparing to supraglottic airway device: a nationwide propensity score-matched cohort study.Resuscitation. 2024; 197: 110129Google Scholar in examining potential benefits of endotracheal tube placement(ETT) versus supraglottic airway device(SGA) in the treatment of drowning victims. Airway intervention in drowning is critical since cardiopulmonary arrest in this scenario is due to systemic hypoxemia, in contrast to acute myocardial ischemia which may present with cardiac arrest due to ventricular fibrillation. In drowning, ETT as compared to SGA potentially has a number of benefits: (1) more secure airway less likely to dislodge during rescue, CPR and transport to the hospital, (2) ability to administer higher pressure breaths which may be necessary if lung compliance is altered due to water aspiration and/or laryngo-bronchospasm, (3) ventilation through ETT doesn't insufflate the stomach, (4) the cuffed ETT provides protection against additional aspiration, the risk of which is increased due to likely water ingestion, and (5) ETT allows access to decompress the stomach with a gastric tube. The primary advantages of the SGA are that it is far easier to place and may be more readily available to lifeguards because it requires a lower level of training for use, while its disadvantages include its propensity to being dislodged and inability to deliver high pressure breaths. Pressures breaching the SGA seal are likely to increase abdominal distension and thereby increase risk of emesis and aspiration. Detecting a breached seal may also be difficult in the loud and often chaotic environment of rescue and transport to the hospital. Yoshimura et al note that SGA failure in drowning was first reported in 2011, appreciating that lung compliance may rapidly decrease by 66% in just minutes with small volumes of sea water aspiration in animal models.2Baker P.A. Webber J.B. Failure to ventilate with supraglottic airways after drowning.Anesth Intensive Care. 2011; 39: 675-677Google Scholar It is likely that these reasons may contribute to the improved ROSC rate with ETT in this study, which is consistent with the only other study examining ETT vs SGA in drowning.3Ryan K.M. Bui M.D. Dugas J.N. Zvonar I. Tobin J.M. Impact of prehospital airway interventions on outcome in cardiac arrest following drowning: a study from the CARES Surveillance Group.Resuscitation. 2021; 163: 130-135Google Scholar It is critically important to provide rapid rescue and airway intervention, and we believe that time to rescue is likely the single most important factor in survival for drowning victims. In fact, in-water resuscitation by professional lifeguards increases survival. Szpilman reported a 15.8% mortality for victims receiving immediate, in-water rescue breathing as compared to 85.2% for resuscitation delayed until return to shore.4Szpilman D. Soares In-water resuscitation- is it worthwhile?.Resuscitation. 2004; 63: 25-31Google Scholar Appreciating the necessity of rapid pulmonary resuscitation, we advocated for early advanced airway placement for select Galveston Beach Patrol lifeguards with advanced airway skills (physician or paramedic) nearly a quarter century ago, all in an effort to reduce the time of hypoxia. Importantly, the most fruitful efforts in reducing drowning fatalities involve factors prior to resuscitation, namely prevention of drowning, proper and timely identification of distress, and prompt rescue- all in an effort to prevent the need for resuscitation as described in the Drowning Chain of Survival.5Szpilman D. Oliveira R.B. Mocellin O. Webber J. Is drowning a mere matter of resuscitation?.Resuscitation. 2018; 129: 103-106Google Scholar Swimming under the watchful eyes of lifeguards is protective, with a fatality rate of only 1 in 18 M visits to beaches protected by United States Lifesaving Association certified agencies. We thank Dr. Yoshimura and group for their efforts in this important area. This publication did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.