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Correspondence |
Vancouver Hospital, Vancouver, Canada, E-mail: rstasiuk{at}vanhosp.bc.ca
To the Editor:
In their article1 the authors, using controlled axial stabilization to simulate standardized intubating conditions, conclude that a StyletScopeTM "is a better intubation tool than a conventional stylet" during difficult laryngeal view. As readers, we understand what a StyletScopeTM is by its physical dimensions, shape, and instruction for use. But what is "a conventional stylet", and when and how should it be employed? The study protocol indicates the manner of intubation, while using a 7.0-mm styletted tube and #3 Macintosh laryngoscope blade, was arbitrarily modified when a single operator subjectively judged that a problem existed during intubation. The tube was introduced under direct vision during grades 1 and 2 laryngoscopies, but moved blindly towards the larynx when the operator determined a grade 3 exposure was present. No attempts were made with grade 4 views.
In principle, this approach vaguely resembles steps that might be followed by some anesthesiologists when confronted with a difficult laryngoscopy. However, we all realize that the practical execution involving laryngoscopy, constructing a styletted tube, and introducing it into the trachea is as varied as the number of anesthesiologists, since no proven and widely accepted system of intubation using a styletted endotracheal tube exists. At best, a description of styletted intubation consists of a few lines in most textbooks ending with a comment that the hockey stick-shaped tube should be used in a fall back technique when conventional intubation fails. Only one conclusion is possible from this paper, that is, the operator was more skilled in using a StyletScopeTM than his personal version of "conventional stylet" intubation, at the time he felt intubation became difficult.
Importantly, one observation confirmed by the study was not addressed. What were the reasons for the unacceptable, high failure rate with styletted intubation during grade 3 laryngoscopies, and why was no attempt made with grade 4 views, since use of a styletted tube is almost always recommended as the first line of defense during problem intubations? The danger of never asking this question lies in never discovering the reasons governing effective use of a styletted endotracheal tube. Without scientific curiosity demanding evidence-based results, the belief that improving outcome during difficult laryngoscopy is achievable solely through developing newer and more complicated instruments beyond the standard laryngoscope, endotracheal tube and stylet, will remain entrenched forever. This mindset avoids the responsibility of acknowledging and dealing with the irrefutable fact that conventional intubation, as again demonstrated in this paper, works well only with simple laryngoscopies but fails progressively as laryngoscopic view deteriorates. Only after the problem is acknowledged can a solution be found by systematically analyzing conventional intubation for its strengths and by improving its weaknesses. The ultimate goal, of course, is to develop a comprehensive method of routine intubation that is practical and equally effective both during simple and difficult laryngoscopies.2
References
1 Kihara S, Yaguchi Y, Taguchi N, Brimacombe JR, Watanabe S. The StyletScopeTM is a better intubation tool than a conventional stylet during simulated cervical spine immobilization. Can J Anesth 2005; 52: 105–9.
2 Stasiuk RB. Improving styletted oral tracheal intubation: rational use of the OTSU. Can J Anesth 2001; 48: 911–8.
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