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REPLY

Toronto, Ontario

A patient with laryngeal tumour presenting with stridor for laryngeal surgery is a daunting situation to deal with. The purpose of our survey was to obtain the anesthesiologist’s first choice for airway management of the scenarios stated.¹

The three most commonly cited options are: awake tracheostomy, awake intubation and intubation following inhalational induction.² Patients who were found to have severe stridor or to have a large or vascular tumour endoscopically should have an awake tracheostomy performed under local anesthetic.²

If the patient is considered possible to intubate, either awake intubation or inhalational induction are possibilities. Awake fibreoptic intubation is an excellent approach to securing a difficult airway. It has been used successfully to manage patients with a variety of obstructive lesions.³ We disagree with the statement that "awake fibreoptic bronchoscope intubation is totally contraindicated in this scenario". The key to successful awake intubation includes adequate topicalization, patient psychological preparation, experienced fibreoptic operator and full preparation to perform tracheostomy should intubation fail.^3,4 Acute airway obstruction has been reported during awake intubation.⁵

Inhalational induction of general anesthesia using sevoflurane is another option.² Adequate anesthetic depth must be achieved before airway instrumentation. Complete airway obstruction and laryngospasm can occur during inhalational induction and one should be fully prepared for a tracheostomy.

I apologize for an error in Table II.¹ Thirty-eight percent of the respondents chose surgical airway, not lighted stylet (erratum published in this issue). It would be inappropriate to use a lighted stylet for an airway with known pathology.

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.[Medline]

3 Ovassapian A. The flexible bronchoscope. A tool for anesthesiologists. Clin Chest Med 2001; 22: 281–99.[Medline]

4 McGuire GP, Wong DT. Airway management: contents of a difficult intubation cart. Can J Anesth 1999; 46: 190–1.[Free Full Text]

5 McGuire G, el-Beheiry H. Complete upper airway obstruction during awake fiberoptic intubation in patients with unstable cervical spine fractures. Can J Anesth 1999; 46: 176–8.[Abstract/Free Full Text]

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