The EasyTube and usersʼ preferences: implications for prehospital medicine and research

Editor, A recent study by Cavus et al.1 has reconfirmed the role of the endotracheal tube as the ‘gold standard’ for airway management by experienced anaesthesiologists. In the present study endotracheal intubation was compared with the ProSeal laryngeal mask (PLMA; Laryngeal Mask Company, Henley-on-Thames, Oxfordshire, UK), the Laryngeal tube S II (LTS II; VBM Medizintechnik, Sulz, Germany) and the EasyTube (EzT; Ruesch, Kernen, Germany) during elective surgery. The primary success rate of insertion of the EzT by an anaesthesiologist was described as ‘very low’: (64% versus 96% for endotracheal intubation. Subjective assessment of the EzT regarding the overall performance was excellent in zero, good in seven, fair in six and poor in nine cases (n = 22). In contrast, Lorenz et al.2 concluded after a clinical trial with fasted adult patients under anaesthesia that ‘Insertion of EzT appears to reduce time and facilitate placement of an airway device when compared with direct laryngoscopy and tracheal intubation’. In my opinion the study presented by Cavus et al. demonstrates very well the role of endotracheal intubation as the ‘gold standard’ for experienced anaesthesiologists. Nevertheless, it is a major limitation of this study that it has been performed in a routine clinical setting by experienced anaesthesiologists. The participating anaesthesiologists were described as ‘six experienced anaesthesiologists introduced to the devices but without any experience in using them’.1 This could explain the low success rate for insertion of the EzT in this study. In an experimental manikin study with 26 paramedics from Telemark, Norway, we compared the EzT, the oesophageal tracheal Combitube (ETC; Tyco Healthcare, Nesbru, Norway) and endotracheal intubation by paramedics.3 Our study showed that the placement success rate was higher with less time required for the ETC and EzT than for endotracheal intubation. Ease of insertion and reduced placement time has been confirmed for the EzT in patients under general anaesthesia.2 After testing, the paramedics in our study3 were asked to state which of the devices they would prefer to use in a real emergency situation (Table 1).Table 1: Paramedic's first choice for a real emergency situationInterestingly the users' preferences differed very much between the experienced anaesthesiologists1 and paramedics.3 In our study3 most paramedics stated that they would prefer the EzT in a real prehospital situation although all of them were trained in endotracheal intubation. The results of the study using anaesthesiologists1 seem to be biased by the great experience that anaesthesiologists certainly do have to perform endotracheal intubation and to use a laryngeal mask whereas they are unfamiliar with the EzT. Therefore, we cannot draw any conclusions about the use of the EzT in the prehospital emergency service and its use by paramedics without doing studies with paramedics in clinical as well as prehospital settings. Based on a review of the existing literature and my own experience as a paramedic and anaesthesiologist I have suggested that the ETC and the EzT should be recommended in the Scandinavian guidelines for prehospital airway management.4 The ETC has been recommended as an alternative airway device in Advanced Life Support by the European Resuscitation Council5 and in ‘cannot ventilate–cannot intubate’ situations by the American Society of Anesthesiologists.6 A review of the existing literature revealed the following main advantages of the Combitube and EzT:4 insertion time is shorter for the ETC and EzT than for endotracheal intubation; better protection against aspiration than a laryngeal mask; the ETC can be inserted with reduced mouth opening and in patients with massive bleeding or regurgitation; the ETC and EzT can be inserted blindly in patients who are trapped in a sitting position (e.g. car crash; author's own experience); epinephrine and lidocaine can be applied via the ETC; mechanical ventilation in intensive care is possible for several hours using the ETC. In general one should be careful to recommend strategies for airway management by paramedics based on studies with participation of experienced anaesthesiologists. The results of the two clinical studies on anaesthetized patients do not provide a definite conclusion about the role of the EzT in airway management in general. More research on the EzT is needed. In conclusion, we need studies to compare the use of the EzT and endotracheal intubation in the clinical and prehospital setting by paramedics in order to find out which role the EzT should have in prehospital airway management.