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REPLY

Dalhousie University, Halifax, Canada, E-mail: hungorla{at}dal.ca

We thank Dr. Stasiuk for his interest in our continuing medical education (CME) program and are grateful for the opportunity to reply. The objective of the CME program was to review recent advances in methods of oxygenation and ventilation. We absolutely accept that every effort should be made to maximize the chances of first attempt intubation success. As previously emphasized by other authors, factors contributing to this success using direct laryngoscopy (DL) include ensuring proper positioning and muscle relaxation; use of an appropriate blade; external laryngeal manipulation;¹ head lift;² and the tracheal tube introducer (TTI) (e.g., Eschmann Tracheal Tube Introducer) or a fibreoptic stylet³ as adjuncts to laryngoscopy. As Dr. Stasiuk points out, difficult DL situations will continue to be encountered, even after applying optimal techniques, due to anatomic variations or pathologic changes of the upper airway. Far from accepting this in an ‘unquestioning manner’, we contend that the anesthesia and airway management community has responded to this potential for DL failure by developing an array of highly effective alternatives, including, but not limited to the laryngeal mask airway Fastrach, the Trachlight, and various rigid, semi-rigid or flexible fibreoptic or video-based devices. These devices have a high success rate independent of the presence of predictors of difficult DL, some even in the hands of inexperienced clinicians.

We appreciate the utility of the oral tracheal stylet unit (OTSU) technique described by Dr. Stasiuk - indeed, one of the authors uses a similar technique when using the Bullard laryngoscope. However with all respect, even a very detailed report of a technique does not necessarily constitute ‘clinical proof’ of its effectiveness. In addition, while a technique may be effective in the hands of a clinician who has developed, thought about, and gradually perfected it, one must also ask if it will be easily learned and applied by less experienced clinicians, performing in a stressful (potentially failed intubation) situation. While a malleable stylet may aid tube placement, attempted blind passage of a styletted tube in grade 3 or 4 situations is not always successful, is potentially traumatic, and has been shown in at least one clinical trial to be inferior to the TTI, at least in the setting of simulated grade 3 views.⁴

We look forward to the publication of a good clinical trial demonstrating the effectiveness of the OTSU technique and its superiority over established adjuncts (e.g., the TTI) or alternatives to DL in grade 3 and grade 4 situations. Until then, we continue to contend, based on published evidence, that a better approach in blind situations than persisting with optimal DL is the use of the TTI or fibreoptic stylet at the initial DL, proceeding on to a non-DL alternative technique as a ‘plan B’ if needed. However, we suspect that Dr. Stasiuk’s OTSU technique may emerge as a useful way to aid tube passage with rigid fibreoptic- or video-based devices such as the Bullard or the Glidescope which permit indirect visualization of the glottic opening.

References

1 Benumof JL. Difficult laryngoscopy: obtaining the best view. Can J Anaesth 1994; 41(5 Pt 1): 361–5.[Free Full Text]

2 Levitan RM, Mechem CC, Ochroch EA, Shafer FS, Hollander JE. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med 2003; 41: 322–30.[Medline]

3 Levitan RM. Design rationale and intended use of a short optical stylet for routine fiberoptic augmentation of emergency laryngoscopy. Am J Emerg Med 2006; 24: 490–5.[Medline]

4 Gataure PS, Vaughan RS, Latto IP. Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet. Anaesthesia 1996; 51: 935–8.[Medline]

Related articles in CJA:

Styletted orotracheal intubation in difficult airway management

Russell B.P. Stasiuk
CJA 2006 53: 1162. [Full Text]  

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