Perceptions of airway protection tools: an international survey on the use of mouthpiece retaining straps in closed-circuit rebreather diving.

Introduction: Rebreather diving carries a high fatality rate (estimated 1.8-3.8 deaths per 100,000 dives), yet its popularity is growing. Among 54 French military divers who lost consciousness underwater, none died when using a mouthpiece retaining strap (MRS) in a team diving setup. Despite this, MRS use remains limited among recreational divers for whom drowning is a major cause of death. This study assessed knowledge, perceptions, and training regarding MRS use within the rebreather diving community. Methods: An international online survey targeting certified rebreather divers was disseminated via social media. The survey gathered demographic information, diving experience, MRS usage, and details on related training. Results: A total of 563 responses were collected. Of these, 133 (23.6%) were instructors, and 210 (37.3%) had received MRS training. On a 0 to 100 scale, divers trained on MRS use rated MRS importance higher (median score: 74 [IQR 33-90]) than divers with no MRS training (median: 49 [IQR 16-67]). Barriers to MRS adoption included negative past experiences, poor training, misuse, and concerns about complications during bailout procedures. Conclusions: While not widely adopted among recreational divers, the MRS is supported by strong safety data. Formal training significantly improves its perceived value and acceptance. Greater involvement from manufacturers, training agencies, and instructors is essential to promote education and encourage MRS adoption as a key safety measure in rebreather diving.