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Department of Anesthesiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
To the Editor:
Juvin et al. (1) support the opinion that difficulty with intubation and view of the larynx during laryngoscopy are independent events (2) and that tracheal intubation is more problematic in the obese. They further suggest the cause of difficult intubation will eventually be discovered by identifying as yet unknown risk factors inherent in obese individuals: that is, the etiology of "difficult intubation" is patient-centered. However, their results indicate the opposite may be true. Failure at initial laryngoscopy in a small, but significant number of patients points to a flaw in the conventional intubating process itself. This study does not recognize that tracheal intubation is complex, involving, in part, two essential and interdependent factors: the physical characteristics of the patient’s airway, and the technical procedure used to guide the endotracheal tube through the laryngoscopic channel. Legitimate and crucial concerns thereby remain overlooked rather than discussed. First, has the chosen method of intubation been critically assessed in its entirety, and, second, is there a better approach to routine intubation that is more effective during difficult laryngoscopy? If an improved method exists, then the term "difficult intubation" becomes Relative one dependent upon the skills of the operator and the format of the intubating process. Consequently, when a single technique of intubation is used, the results are applicable only to that style of intubation and cannot be generalized to all patients.
An obvious question arises. Is there a novel method of routine intubation that will safely improve success rates in a diverse patient population, and if the answer is "yes," why is it more effective? One practical alternative does exist. It is a method of styletted endotracheal intubation comprised of well-defined steps that follow the rules governing tracheal intubation (2). This technique mandates use of a specifically shaped, styletted endotracheal tube and ultimately allows the operator to intentionally guide the endotracheal tube into the glottis when grades I–III views are produced at laryngoscopy. The complete technique, refined from thousands of successful routine intubations, has been consistently effective in a broad cross-section of patients, and its use constitutes improved management during "difficult tracheal intubation."
References
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