Training and experience are more important than the type of practitioner for intubation success

Lossius and colleagues compared ETI success rates of highly trained anaesthesiologists and emergency physicians from northwestern Europe with paramedics and nurses from the rest of the world [1]. One study incorporated in their meta-analysis included rural basic emergency medical technicians with no previous ETI experience [2]. Perhaps unsurprisingly, the authors showed increased ETI success rates for highly trained physicians compared with such a varied group of nonphysicians. However, our re-analysis suggests that the differing level of ETI training between clinicians, not the type of clinician, might be more important for successful ETI.Hans Morten Lossius, David J Lockey and Jo R？islienThank you for your interest in our recently published paper [1]. Our article makes it quite clear that we consider training of key importance in intubation success rates. While training may be more important than the type of provider, the type of provider is often a marker of level of training. We point out that there is considerable variability in paramedic training, and to a lesser extent physician training, in different emergency medicine systems. However, well-trained anaesthesiologists are likely to have more training and experience in advanced airway management than even well-trained paramedics. We looked at one large study involving paramedics trained to a high level, higher than most emergency medicine systems are able to resource, and found that intubation failure rates were higher than for undifferentiated physician intubation. We believe our publication provides evidence that paramedics, even with good training but limited regular exposure to advanced airway management, have a higher intubation failure rate than physicians with high exposure to in-hospital and out-of-hospital advanced airway management.Advanced airway management must be considered a complex intervention in which the ETI procedure is one of many factors influencing outcome [3,4]. In-hospital advanced air