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Canadian Journal of Anesthesia 50:1080 (2003)
© Canadian Anesthesiologists' Society, 2003

Correspondence

Management of the unanticipated difficult airway using a modified sequential intubation technique

Michael Lim, FRCA* and Jonathan Casement, FRCA{dagger}

* London
{dagger} Stoke-on-Trent, UK

To the Editor:

Leoni et al.1 are to be congratulated on the successful outcome to a technically-difficult life-threatening situation. By first oxygenating the patient, and only then attempting to intubate the trachea, they have beautifully illustrated the golden rule for the difficult airway – that patients die from failure to oxygenate, not failure to intubate.

Whilst impossible to criticize the final result, we wish to comment upon two areas.

Firstly, we would question the value of drawing arterial blood for blood gas analysis whilst still attempting to ventilate via face-mask. The inadequacy of gas exchange is all too obvious from the clinical picture. An investigation should only be performed if its result may alter the patient’s management, and clearly, tracheal intubation was inevitable. To make matters worse, the physician taking the arterial sample is being diverted from the urgent priority of resuscitating the patient.

Secondly, most endotracheal tubes are not long enough to avoid the risk of its cuff sitting over or above the vocal cords when passed through the laryngeal mask airway (LMA).2 This increases the risk of accidental extubation when removing the LMA, in addition to preventing the administration of high positive airway pressures and positive end-expiratory pressure. A solution would be using the Aintree intubating catheter3 (Cook Critical Care, IL, USA). This is a modified airway exchange catheter that fits over the bronchoscope. It is 56 cm long, allowing greater control of the airway and oxygenation to continue, via its Rapi-fit® connector, whilst rail-roading the endotracheal tube over it. A purpose-built solution for this situation.



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  		FIGURE Aintree catheter mounted onto fibreoptic bronchoscope and passed through a laryngeal mask airway.

 
References

1 Leoni A, Crescenzi G, Landoni G, Castracane W, Zangrillo A. Use of the laryngeal mask airway and a modified sequential intubation technique for the management of an unanticipated difficult airway in a remote location (Letter). Can J Anesth 2003; 50: 523–4.[Free Full Text]

2 Asai T, Latto IP, Vaughan RS. The distance between the grille of the laryngeal mask airway and the vocal cords. Is conventional intubation through the laryngeal mask safe? Anaesthesia 1993; 48: 667–9.[Medline]

3 Atherton DP, O’Sullivan E, Lowe D, Charters P. A ventilation-exchange bougie for fibreoptic intubations with the laryngeal mask airway. Anaesthesia 1996; 51: 1123–6.[Medline]


Related articles in CJA:

REPLY
Albino Leoni and Giovanni Landoni
CJA 2003 50: 1080-1081. [Full Text]  




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