Galeiras Vázquez et al. make an excellent review of post-traumatic spinal cord injuries, but we do not agree on the recommendation to use first the Airtraq® device as an alternative to direct laryngoscopy, or the statement that there is a lack of evidence confirming the utility of other devices.1

They stand for the use of Airtraq® in one meta-analysis of 24 trials that compared different devices that may be an alternative to the Macintosh laryngoscope blade.2 In all the trials, the operator is an experienced anesthesiologist, and there are zero patients with difficult intubations – something that could be expected, included in the trials; both facts are far from the actual clinical scenario of post-traumatic spinal cord injuries: polytraumas that require the isolation of the airway in the extra-hospital setting, or hospital emergency services by doctors who are not anesthesiologists; and that require urgent care which, given their adverse physiological conditions, makes patient's airway extremely difficult to handle. Also, an obvious limitation reported in this device and video laryngoscopes, in general, is the loss of visualization due to the blood and secretions occupying the lens – a common thing in these patients.

Contrary to all this, the Fastrach™ intubating laryngeal mask is widely used in all extra-hospital and hospital ERs, and there are multiple studies confirming high rates of success in the ventilation and blind intubation procedures performed by medical sand non-medical staff with and without prior training.3

Out of the 24 trials included in the aforementioned meta-analysis, only the study conducted by Gercek et al.4 includes the Fastrach™ and shows less movement of the cervical spine and shorter intubation times than what has been reported with direct laryngoscopy procedures, while exposing its utility for the management of airways after spinal cord injuries.

So far, the reviews that advise against the use of supragottic devices while managing potential or confirmed cervical spinal cord injuries are based on the conclusions drawn by a study conducted by Keller et al.5 that shows an increased pressure against the cervical vertebrae. The study included 20 cadavers but, as the authors say, the model cannot be extrapolated to physiological conditions due to the lower temperature and higher rigidity of the pharyngeal musculature. We should add here that in all cadavers, the size 5 Fastrach™ blade was used (recommended for patients weighing around 70–100kg), when the authors describe that their study population weight was in the 50–93kg range. This means that there is an undetermined number of cases where bigger sizes are being used with the corresponding risk of tissue lesion, and intubation failure, and probably another contributing factor for the negative results reported in such study.

We believe that the Fastrach™ intubating laryngeal mask is a safe and widely used device that can be used for ventilation and intubation of patients with suspected or confirmed cervical spinal cord injuries.