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LETTER TO THE EDITOR

The Importance of a Laryngoscopy Strategy and Optimal Conditions in Emergency Intubation

Senior Associate, Anesthesiology; Associate Director, Surgical ICU; Hartford Hospital; University of Connecticut School of Medicine; Hartford, CT; tmort{at}harthosp.org

In Response:

I appreciate Dr. Levitan’s comments that emergency airway management complications are numerous and rise dramatically beyond two attempts (1). This support’s the recommendation, based on a consensus opinion, that alternative methods be pursued when difficulty is encountered and attempts should be limited to three (2). There are no standardized parameters that define airway complications, thus reporting is inconsistent. Current literature reports few complications (3–6) but self-reporting is a limitation since underreporting is common (7–9).

A strategy for first-pass success must stress patient safety, not just "getting the tube in." Must "optimal laryngoscopy" involve neuromuscular blocking agents? I seem to be better able to answer this after completion of intubation, not before. Is RSI being used to minimize aspiration risk or to optimize laryngeal viewing or both? Optimizing the view courtesy of paralysis is not guaranteed and negates both the experience and skill of the intubator and the patient’s individual airway characteristics. Although our skills of reliably predicting the difficult airway are imperfect, a prudent approach of maintaining spontaneous ventilation when facing the potential of difficult mask ventilation, laryngoscopy, or intubation should be considered. I would be hard pressed to replicate a 98% rate of RSI if one avoids paralysis when anticipation of airway difficulty exists (5). Maintaining spontaneous ventilation is not necessarily equivalent to an "awake" approach.

Reanalysis of this database does not suggest RSI is safer than non-RSI techniques (6,10) (Table 1).

When one prepares for airway management, we should be practiced in asking ourselves three questions (surgical versus nonsurgical approach, awake versus asleep, and paralysis versus no paralysis) (1) based on the patient’s needs and the practitioner’s experience, judgment, and capabilities in concert with available personnel, equipment, and facilities. We need to raise the bar on airway management by encouraging that a rapid sequence intubation/induction be pursued only when the airway team is skilled and experienced with the use of advanced airway rescue equipment and such equipment is immediately available to the practitioner at the bedside. Optimal conditions, however, are uncommon in the GI suite, the "cath lab," or the family lounge.

Both non-RSI and RSI approaches entail risk. The controversy continues.

References

1. Mort T. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004;99:607–13.[Abstract/Free Full Text]
2. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269–77.[Web of Science][Medline]
3. Sanborn KV, Castro J, Kuroda M, et al. Detection of intraoperative incidents by electronic scanning of computerized anesthesia records. Anesthesiology 1996;85:977–87.[Web of Science][Medline]
4. Katz RJ, Lagasse RS. Factors influencing the reporting of adverse perioperative outcomes to a quality management program. Anesth Analg 2000;90:344–50.[Abstract/Free Full Text]
5. Over D, Pace N, Shearer V, et al. Clinical audit of anaesthesia practice and adverse peri-operative events. Eur J Anaesthesiol 1994;11:231–5.[Web of Science][Medline]
6. Tayal VS, Riggs RW, Marx JA, et al. Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period. Acad Emerg Med J 1999;6:31–7.[Web of Science][Medline]
7. Sakles JC, Laurin EG, Rantapaa AA, et al. Airway management in the emergency department: a one-year study of 610 intubations. Ann Emerg Med 1998;31:325–32.[Web of Science][Medline]
8. Levitan RM, Rosenblatt B, Meiner EM, et al. Alternating day EM and anesthesia resident responsibility for management of the trauma airway: a study of laryngoscopy performance and intubation success. Ann Emerg Med 2004;43:48–53.[Web of Science][Medline]
9. Li J, Murphy-Lavoie H, Bugas C, et al. Complications of emergency intubation with and without paralysis. Am J Emerg Med 1999;17:141–3.[Web of Science][Medline]
10. Bair AE, Filbin MR, Kulkarni RG, et al. The failed intubation attempt in the emergency department: analysis of prevalence, rescue techniques, and personnel. J Emerg Med 2002;23:131–140.[Web of Science][Medline]

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