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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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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
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