To the Editor We read with great interest the recent study¹ about the effect of noninvasive airway management of comatose patients with acute poisoning, but are concerned about potential issues related to selection bias, confounding factors, and the unblinded study design that might have biased the results toward the intervention group (conservative strategy).

First, assessing the level of consciousness in nontraumatic comatose patients is a challenge, especially given the limited validation of the GCS for patients without trauma and regarding decisions about intubation.² A prior study showed that approximately 36% of patients with a GCS score less than 9 had a normal gag reflex, suggesting intubation may not be necessary to prevent aspiration in these patients.³ Furthermore, assigning a GCS score involves some subjective judgment, which may lead to interobserver variability.⁴ The percentage agreement for GCS scoring among physicians was not reported in this study,¹ which could lead to potential misclassification of patients in this study.