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Department of Anesthesiology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH
To the Editor:
Muraika et al.’s (1) interesting discussion following the case report inspires me to make two points. First, in listing some alternate tracheal intubation techniques, they omit one widely available and most cost-effective and efficient technique, that is, digitally assisted tracheal intubation (2,3). In infants and children, digitally assisted intubation requires one index finger and may be performed with or without topical anesthesia, with or without IV or inhalational general anesthesia and during spontaneous breathing or after the administration of muscle relaxants. It generally takes less than 1 minute to perform. In pediatric patients with hypoplastic mandible, its efficiency and availability may make digitally assisted tracheal intubation the technique of choice. Second, my opinion differs from that of the authors who "do not suggest abandoning direct laryngoscopy as a first look." I believe one’s preferred alternate technique should be employed as the first line approach whenever difficult direct laryngoscopy seems reasonably likely, rather than kept in reserve as a back-up to be used only after direct laryngoscopy has failed. Our anesthesia group has found that this approach leads to significantly greater use of, comfort with, and development of mastery of our alternate techniques. After all, in order to teach, learn, or even maintain optimum efficiency and effectiveness in digitally assisted or another alternate technique of endotracheal intubation such as fiberoptic intubation, the technique must be performed regularly. Thus, I suggest that we anesthesiologists choose an alternate technique to direct laryngoscopy, use that technique first whenever difficult direct laryngoscopy is suspected and not forget the simple, cost-effective, efficient, and potentially life-saving technique of digitally assisted tracheal intubation.
References
St. Christopher’s Hospital for Children, Philadelphia, PA
In Response:
We appreciate Dr. Gordon’s interest in our article and his recommendations. He suggested adding digital assisted tracheal intubation to the list of alternative methods of intubating children with known difficult airways. This technique has been well described, particularly in children and infants, and we feel it should have completed our list of alternative intubation techniques (1). Regarding the usefulness of this technique in our case report, the authors feel the child’s extreme limited mouth opening would have precluded us from palpating the glottis and achieving digital assisted intubation. Also, we have found intubation of the airway in children with Treacher Collins to be a greater challenge than those with Pierre Robin syndrome. Frequently, the authors have found success in our first attempt at direct laryngoscopy in patients with Pierre Robin syndrome. Perhaps digital assisted intubation is more easily facilitated in these patients than those with Treacher Collins syndrome. Although both syndromes fall into the category of a difficult pediatric airway, we feel the approach for intubation should be specific for each syndrome. Finally, Dr. Gordon advocates the use of alternative intubating techniques as a first attempt in intubating a difficult airway. The authors prefer to err on the side of caution and attempt direct laryngoscopy first—the technique we are most skilled at performing. We advocate alternative techniques of intubation of a difficult pediatric airway as the first attempt only if the anesthesiologist is experienced and skilled with that particular technique.
Reference
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