To the Editor

A forum on “Airway Management Continues to Raise Safety Concerns” regularly includes current recommendations on ways to secure a jeopardized airway after attempts at endotracheal tube placement during “difficult intubation” fail.¹ At this stage an effective rescue technique, without question, becomes the only available option to avoid patient injury.

In retrospect many questions must always be asked, including—why did conventional intubation fail, and what technical changes are necessary to improve outcome? To date, the answers have ranged from developing scoring systems in the attempt to pre-emptively identify patients at risk, bettering laryngoscopic view via, for example, altering head position, and assigning cause for difficult intubation to patients’ physical characteristics such as obesity.²

The focus on modifying selective aspects of the intubating procedure, however, is based on unproven assumptions about the intubating process itself. Current opinion accepts the principle that oral tracheal intubation, as presently practiced, is the correct way to intubate, since historically it has proven reliable for most intubations and problematic only in a small percentage of cases, the latter constituting “difficult intubations.” Longevity, along with absence of a reliable alternative, has, by default, made the current method the standard—to be refined, but never questioned. However, is this reasoning correct, and would using an alternate approach that combines uncomplicated intubation of normal patients with a seamless transition to intubate successfully during “difficult intubations” be desirable? Any such technique would enhance safety by significantly reducing the number of patients requiring emergency airway management, many under adverse circumstances.

The need for a new technique that improves outcome during difficult laryngoscopy, should therefore, at the very least, be recognized and discussed. Only then can the strengths and weaknesses of conventional intubation be debated, and the fundamental factors governing successful tracheal intubation recognized. Failure to do so only propagates the status quo without significantly improving management of unanticipated “difficult intubations.”

In practice, does a viable alternative exist, and on what concepts is it based? A complete system for intubation that requires mandatory use of a styleted endotracheal tube and follows obligatory rules has been used successfully for many years in a variety of clinical conditions.³ I submit that this technique used routinely in the hands of trained operators is a major advance in oral tracheal intubation.

Many experienced anaesthesiologists will not accept the suggestion that their personal method of intubation may be improved, while others search for answers to problems they have encountered. However, the issue of how best to perform oral tracheal intubation should be accepted for what it is, an unresolved clinical problem, with solutions that must meet the criteria of evidence-based medicine. Only then will fact be separated from bias.

Russell B. P. Stasiuk, MD
Vancouver, British Columbia

References

1. 2003 ASA Meeting Highlights Safety. APSF Newsletter 2003;18:33, 34, 36.
2. Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg 2003;97:595-600.
3. Stasiuk RBP. Improving styletted oral tracheal intubation: rational use of the OTSU. Can J Anesth 2001;48:911-18.