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Anesth Analg 2005;100:900
© 2005 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000146655.91764.89


LETTER TO THE EDITOR

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

Thomas C. Mort, MD

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).


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Table 1. Complications: Non-RSI vs. RSI

 

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.[ISI][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.[ISI][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.[ISI][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.[ISI][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.[ISI][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.[ISI][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.[ISI][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.[ISI][Medline]




This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
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Right arrow Email this article to a colleague
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Citing Articles
Right arrow Citing Articles via ISI Web of Science (3)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mort, T. C.
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PubMed
Right arrow Articles by Mort, T. C.


Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press