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Letter to the Editor
In reply to “Fastrach™ intubating laryngeal mask for traumatic cervical spinal cord injury”
En respuesta a «Mascarilla laríngea para intubación Fastrach® en la lesión medular cervical postraumática»
R. Galeirasa,
Corresponding author
ritagaleiras@hotmail.es

Corresponding author.
, M. Moureloa, M.E. Ferreirob, S. Salvadorb, A. Montotob
a Servicio de Medicina Intensiva, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Sergas, Universidade da Coruña (UDC), A Coruña, Spain
b Unidad de Lesionados Medulares, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Sergas, Universidade da Coruña (UDC), A Coruña, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It has taken decades to develop and refine the main principles for the stabilization of the cervical spinal cord in patients with suspected or confirmed cervical damage&#46; Under urgent circumstances in the extra-hospital setting&#44; the endotracheal intubation is preferred over the ventilation with Ambu bag&#44; or cricothyroidotomy&#46; The in-line stabilization of the cervical spinal cord guarantees safe intubations when conducted through direct laryngoscopy&#46; In the critical care and emergency settings it is advisable to have a good theoretical and practical command of five &#40;5&#41; basic instrumental modalities&#58; the facial mask&#44; one direct laryngoscope and its complements&#44; one indirect laryngoscope&#47;video laryngoscope&#44; one extraglottic device &#40;being the Fastrach<span class="elsevierStyleSup">&#174;</span> laryngeal mask the most efficient of all&#41;&#44; and one technique with urgent subglottic access for non-intubable and non-ventilable patients&#46; There is a double target here&#58; be able to stop the progressive drop of SpO<span class="elsevierStyleInf">2</span> levels until reaching dramatic values and be &#8220;ready to fail&#8221;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Even when the manual in-line stabilization is being used&#44; the intubation with laryngeal mask exerts forces to the cervical spinal cord that are different from the ones exerted by the direct laryngoscopy&#46; Sawin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> showed that the direct laryngoscopy elongates every cervical segment&#44; particularly at atlantoaxial level&#46; A study conducted by Kihara et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> showed that intubations with laryngeal masks produce the flexion and posterior displacement of the cervical spine cord even when the manual in-line stabilization is being used&#46; Keller et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> and Brimacombe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> used cadavers to study the forces exerted during intubations with laryngeal masks with and without manual in-line stabilization of the cervical spinal cord&#44; respectively&#44; and confirmed the presence of posterior displacement&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">These recent findings can have several clinical implications&#46; Sawin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> speculate with the possibility that the direct laryngoscopy can be potentially more harmful in patients whose cervical segments are more unstable when elongated&#44; while Kihara et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> believe that intubations with laryngeal masks can be more harmful in patients whose necks are unstable on flexion &#8211; the most common lesion&#46; But these risks have not been quantified yet&#44; and the priorities during the management of the airways&#44; in urgent situations&#44; in patients with real or potential cervical spinal cord injuries are the ventilation and protection of such airways&#46; The direct laryngoscopy is still the technique of choice for urgent intubations in most of these patients who suffer flexion injuries in their necks&#46; This technique is faster&#44; less affected by the application of cricoid pressure&#44; and less likely to negatively damage the biomechanics of the neck commonly hurt by flexion&#46; We would consider the intubation with laryngeal mask as the first option for the urgent endotracheal intubation of patients with a known mechanism of neck injury resulting from excessive elongation&#46; We would use the intubation with laryngeal mask as a second option for the tracheal intubation of patients when the direct laryngoscopy has failed to succeed&#46; Yet this requires not only the immediate availability of the device&#44; but also training on how to use it &#8211; two requirements that are not always present&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; the indirect methods of intubation cause less cervical movements than conventional laryngoscopies&#44; and today they are preferred during the elective intubation of patients at risk of cervical spine cord injuries&#44; because they allow intubations in neutral positions&#44; improve the field of view of the glottal region&#44; and minimize laryngeal traumas&#46;</p></span>"
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