Volume 83, December 2025, 101708Author links open overlay panel, , , , , , Section snippetsResponse to Kumar et al

We would like to thank Kumar, Mehta, and Sah for their thoughtful and constructive commentary [1] on our recently published systematic review [3] regarding suction-based airway clearance devices (ACDs) for foreign body airway obstruction (FBAO). We appreciate the opportunity to address the points raised and provide clarification on key methodological and clinical issues.

Clarification on study exclusion discrepancy

The authors correctly noted a minor inconsistency between the number of full-text articles excluded (as stated in the manuscript) and the figure reported in the PRISMA diagram. We would like to clarify that one article, initially considered eligible during preliminary screening, was later excluded upon more rigorous analysis due to not fully meeting our predefined inclusion criteria, as established in our published protocol [4]. Nevertheless, we believed the content of that study to be relevant

Justification for using the Crowe Critical Appraisal Tool (CCAT) instead of GRADE

Regarding the suggestion to use the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) framework, we agree that it has become a widely adopted tool for assessing the certainty of evidence and informing clinical recommendations [5]. However, our decision to employ the Crowe Critical Appraisal Tool (CCAT) was deliberate and based on the methodological nature of the studies included. As noted in our review, the evidence base on suction-based ACDs currently comprises a

Clinical and ethical considerations for real-world ACD implementation

We are grateful for the suggestion to expand upon the clinical and ethical dimensions surrounding ACD use, which we agree deserve further reflection. Although our primary objective was to evaluate the current state of evidence, we recognize that the real-world applicability of these devices extends beyond methodological rigor alone. In particular, suction-based ACDs may offer distinct advantages in populations where traditional techniques are impractical or contraindicated, such as in obese

Response to Gould

We acknowledge the interest of Mr. Gould in our work and appreciate his engagement with the topic. However, several of his assertions reflect a misunderstanding of both our methodological framework and the fundamental distinction between regulatory approval and scientific evidence. Our review aimed to systematically appraise the published literature, not the internal regulatory data or manufacturer reports. Regulatory clearance establishes that a device meets safety and performance requirements

On the references cited by Gould

We also note that several of the references cited by Mr. Gould require careful contextualization regarding their evidentiary strength and independence. For instance, the ANZCOR Guideline 4 – Airway Management [12] is consistent with the broader ILCOR framework, which recognises the limited evidence underpinning all FBAO interventions but does not endorse suction-based devices for routine use. The retrospective 10-year review by Costable et al. [13] represents manufacturer-reported surveillance

Conclusion

In summary, our systematic review followed PRISMA standards, was registered in PROSPERO, and applied transparent, pre-specified inclusion criteria. We reaffirm our conclusions that suction-based ACDs, including LifeVac® and DeChoker®, represent potentially valuable adjuncts in FBAO management but that independent, high-quality evidence is still required to define their role relative to conventional interventions. We thank both commentaries for fostering constructive debate on this important

Ethical approval

Not applicable.

Funding

Not applicable.

Human Ethics

Not applicable since no human participants were involved in this article − Consent for publication: Not applicable.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

None.

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