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LETTERS TO THE EDITOR

"Quick Look" Direct Laryngoscopy to Avoid Cannot Intubate/Cannot Ventilate Inductions

East Granby, CT

To the Editor:

It amazes me that multiple attempts at direct laryngoscopy continue to result in situations such as that described by Muraika et al. (1), where "mask and bag ventilation became more difficult... ." Have we not learned anything over the last 12 years since Benumof’s "Management of the Difficult Airway" (2)? Furthermore, and as a practical matter, by not commonly employing alternative techniques, anesthesiologists squander the opportunity to become intimately familiar with, practiced, and speedy at all their backup options.

In case of any significant doubt at all, my own technique is induction with a standard dose of propofol, and one, gentle "quick look" with direct laryngoscopy. If the quick look shows little promise of success with that or an alternative blade, direct laryngoscopy is abandoned for another technique. No anesthetic other than propofol is given before the quick look—especially no opioid—so that rapid return of spontaneous ventilation is assured.

Curiously, the quick look is not described in the ASA difficult airway algorithm despite its popular familiarity, and 100% reliability (by definition) in avoiding the kind of attempted intubation involving multiple direct laryngoscopies, that turns into a cannot intubate/cannot ventilate scenario. Moreover, the quick look is easily employed, costs nothing, and takes only seconds, thereby causing no delay in the induction process. The surgeons don’t even notice. I use it frequently and without hesitation.

One caveat in regards to pediatric cases: a quick look under propofol anesthesia may predispose to laryngospasm upon airway stimulation. A safer avenue may be a sevoflurane inhalation induction with spontaneous ventilation to an end-tidal concentration almost sufficient to cause apnea, followed by the quick look.

Although certainly worthy of appropriate respect, just like patients with any number of other severe diseases, the patient with the "difficult intubation" should no longer be considered Rarity, something that requires "special" attention and facilities. We have the technology to intubate the trachea via so many techniques other than conventional direct laryngoscopy. We should equally have the familiarity and the facility to use them, with complete ease, and without considering it something out of the ordinary.

References

1. Muraika L, Heyman JS, Shevchenko Y. Fiberoptic tracheal intubation through a laryngeal mask airway in a child with Treacher Collins syndrome. Anesth Analg 2003; 97: 1298–9.[Abstract/Free Full Text]
2. Benumof JL. Management of the difficult adult airway: with special emphasis on awake tracheal intubation. Anesthesiology 1991; 75: 1087–110.[Web of Science][Medline]

Response

St. Christopher’s Hospital for Children, Philadelphia, PA

In Response:

Thank you for your interest in our case report. During my adult training, I, like you, have proceeded in accordance with Dr. Benumof’s difficult airway algorithm when having been faced with a difficult airway. However, the pediatric patient is not, and cannot be treated as a small adult. Using a pediatric difficult airway algorithm (1), our approach to intubation of the child with Treacher Collins syndrome follows standard options and methods outlined in this algorithm. Your "quick look" technique after a bolus of propofol is omitted both from the ASA’s difficult airway algorithm and the difficult pediatric airway algorithm. Although you have found success with your "quick look" approach in the adult population, I would not recommend it in the pediatric setting for the following reasons. If a suboptimal dose of propofol is given and intubation is attempted, laryngospasm is likely to occur. On the other hand, if too large a dose of propofol is given, the patient may lose spontaneous respirations. Your suggestion of performing a "quick look" after sevoflurane induction of anesthesia is reasonable; however, we feel that this technique of deep inhalation manipulation or intubation without muscle relaxation may predispose the child to laryngospasm. A safer alternative is to check your ability to ventilate during spontaneous respirations, and then give a short acting muscle relaxant before attempting direct laryngoscopy.

Reference

1. Bissonnette B, Dalens B. Pediatric anesthesia: principles & practice. New York: The McGraw-Hill Companies, 2002: 483–503.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Stemp, L. I. Articles by Muraika, L. A. Search for Related Content PubMed PubMed Citation Articles by Stemp, L. I. Articles by Muraika, L. A.