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Correspondence |
Vancouver, British Columbia
To the Editor:
The authors of the article, "The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet," conclude that a styletted endotracheal tube (ETT) hinders intubation while the sentence, "both a stylet and a gum elastic bougie are simple adjuncts for tracheal intubation," defines the accepted role of a stylet in routine tracheal intubation.1 In practice when intubation with a plain ETT fails, by definition that intubation becomes a "difficult intubation" requiring the operator to introduce added measures such as an ETT with a stylet. It is precisely our failure to question the entire process of intubation that has prevented identification of an obvious problem and its answer: since current intubation fails in a small number of patients an important solution lies in improving the intubating technique itself by following rules governing passage of the ETT through the laryngoscopic channel.
One described method incorporates these considerations.2 In part it requires routine use of an ETT with a specific shape maintained by a stylet and directed in a prescribed manner within the upper airway. In contrast, the hurried insertion of a recycled stylet into an ETT hoping that it might somehow help does not constitute correct use of a styletted ETT. The two are simply a combination that is tried as an afterthought during difficult laryngoscopy.
In the current study the classic hockey stick curve, created by a well-lubricated stylet, was not helpful since the stylet was not an integral component of a planned and practiced system, and the failure to intubate two of 60 patients at initial laryngoscopy is an example of the problem inherent in the current method. The solution therefore requires critical examination of important steps governing both old and new procedures, and the ultimate acceptance of a more advanced technique that is both practical and effective.
References
1 Noguchi T, Koga K, Shiga Y, Shigematsu A. The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet. Can J Anesth 2003; 50: 712–7.
2 Stasiuk RB. Improving styletted oral tracheal intubation: rational use of the OTSU. Can J Anesth 2001; 48: 911–8.
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