First of all, we wish to thank Gómez-Ríos et al. for their comments,1 and for their interest in our work. Their letter comments on different aspects of our survey, and data from it are used to continue placing emphasis on the existence of major problems in relation to airway management in the critical patient.

We wish to underscore that although there has been an increase in the number of publications in this field in recent years, no specific management guides referred to critical care were forthcoming until the publication in 2017 of the British guidelines by the Difficult Airway Society (DAS).2 These guidelines appeared in parallel to our own survey; consequently, we were unable to make any mention of them. Nevertheless, our findings have revealed that there is considerable room for improvement in airway management in the ICU; in this respect, the availability of recommendations for homogenizing such management may have an effect upon critical patient morbidity-mortality. Subsequent studies will be needed to evaluate the impact of these recommendations in routine clinical practice.

The evaluation of predictors of difficult intubation is useful in the planning of rescue strategies, making it possible to shorten the intervention times in the event of complications.3 The use of combined predictors has been shown to afford increased sensitivity and specificity in detecting a difficult airway compared with the use of a single predictor.4 In recent years, some studies have demonstrated the validity of the MACOCHA scale in the ICU5; nevertheless, the assessment of airway anatomy in the critically ill is usually difficult due to the scarce functional reserve and instability of these patients. Instruments such as the Mallampati scale (included in the MACOCHA scale with a high score) may prove difficult to apply. Despite this, and even in emergency situations, the existence of difficult airway predictors must be taken into account.

Capnography is very important for discarding failed intubation by corroborating correct positioning of the endotracheal tube. Although it is widely used in the intraoperative setting, we admit that the lack of an item asking about the availability of capnography is one of the weaknesses of our survey – its use having been recommended since the publication of the NAP4.6

In conclusion, while much remains to be done in airway management in the ICU, the fact that recommendations for routine clinical practice are becoming available may imply changes in terms of patient morbidity-mortality. Further studies will be needed to evaluate the impact of these recommendations and to establish new critical airway management protocols.