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Management choices for the difficult airway

Victoria, Australia

To the Editor:

We read with great concern the article by Jenkins et al. (October 2002).¹ Their survey showed that in "Clinical Scenario number 3 - Laryngeal tumour with stridor for laryngectomy," 90% of anesthesiologists would perform an awake intubation, 45% of which would use fibreoptic bronchoscope (FOB) and 38% a lighted stylet.

This is very dangerous practice and could result in death of the patient. Best anesthetic practice is either 1) gas induction of anesthesia, maintaining spontaneous respiration, and when deep enough using a rigid laryngoscope (our preference is the tubular Lindholm scope as it opens up the posterior pharyngeal space and pushes tumour or edema out of the way). 2) If the patient is deemed to have an extremely compromised airway then an awake surgical tracheostomy is indicated.²

Awake FOB intubation is totally contraindicated in this scenario for the following reasons:

1) lidocaine spray or FOB stimulation to the cords will result in irreversible laryngospasm in these patients; 2) a 4-mm FOB is inadequate in this situation due to a narrow field of view, distorted anatomy, potential bleeding from a friable tumour, and a narrow or closed posterior pharyngeal space; 3) if you were lucky enough ‘God willing’ to insert the FOB into the larynx of this airway compromised patient, the sheer terror of now completely occluding the airway would result in an acutely distressed uncooperative patient. An extremely ugly and potentially deadly situation.

We also consider the use of the lighted stylet to be totally inappropriate to this scenario.

Also of concern is that the appropriateness of this practice was not challenged in either the discussion section of the article or in the accompanying editorial.³

We refer you to an extremely useful editorial that we commend to your readers.²

We suspect that the results of your Canadian survey reflect similar opinions in Australia, our "Difficult Airway Societies" will have to work harder to inform and teach best practice airway skills.

References

1 Jenkins K, Wong DT, Correa R. Management choices for the difficult airway by anesthesiologists in Canada. Can J Anesth 2002: 49: 850–6.[Abstract/Free Full Text]

2 Mason RA, Fielder CP. The obstructed airway in head and neck surgery. Anaesthesia 1999; 54; 625–8.

3 Hung O. Airway management: the good, the bad, and the ugly (Editorial). Can J Anesth 2002; 49: 767–71.[Free Full Text]

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