Tracheal intubation of morbidly obese patients
Reading, UK
* E-mail: awaneekumar{at}doctors.org.uk
Editor—I read with great interest the paper by Dhonneur and colleagues1 on tracheal intubation of morbidly obese patients: LMA CTrachTM vs direct laryngoscopy (DL). It was very impressive that they were not only successful in tracheal intubation of all patients using LMA CTrachTM (CT), but also were able to view the advancing tracheal tube through the glottis. In the DL group 17% of patients with Cormack and Lehane grade 3 required a gum elastic bougie to assist tracheal intubation, resulting in total and partial blind intubations. The down side being the average duration of tracheal intubation being 119 s in DL group and 176 s in CT group. Previous papers2 3 using CT showed 100% success rate in ventilation of patients and a 96% success rate in tracheal intubation either blindly or viewing the tracheal tube passing through the vocal cords. In a study by Baskett and colleagues4 involving ILMA, a multicentre trial with 500 patients showed a success rate of 90% in tracheal intubation. In all these trials, most of the failures in tracheal intubation using CT and ILMA happened in the first 20 attempts of inserting the airway device by the anaesthetist as per the manufacturer's recommendations. This clearly indicates that the more experience one has the more likely is the success.
My concern is the level of competency achieved by trainees in anaesthesia in handling these airway devices. I recently conducted a survey among 20 trainees at different levels of training regarding the level of competency achieved by trainees in different airway devices (Table 1). This survey was conducted at the Royal Berkshire Hospital, Reading, which has been the pioneer and a leading force in the invention and use of airway devices like Classic LMATM, ILMA, and CT. Most of the trainees replied that though they were trained for the use of the devices, they were not confident of using ILMA, fibre-optic intubation (FOI) and CT in an emergency situation. They expressed a need for more training in these devices; 16 trainees did not receive any formal training in LMA CTrach, 14 felt a need for more training in the use of FOI technique, and 8 felt though they were trained in ILMA and fibre-optic system they were not confident using it independently and in an emergency situation.
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The survey group was small and there is a need for a larger study regionally and nationally. It is difficult to deny the fact that there is a necessity for more training in the use of the above-mentioned airway devices.
Acknowledgements
The author would like to acknowledge the assistance of Dr Chandy Verghese and the Department of Anaesthesia, Royal Berkshire Hospital, Reading, UK.
References
1 Dhonneur G, Ndoko SK, Yavchitz A, et al. (2006) Tracheal intubation of morbidly obese patients: LMA CTrachTM vs direct laryngoscopy. Br J Anaesth 97:742–5.
2 Liu EHC, Goy RWL, Chen FG. (2006) The LMA CTrachTM, a new laryngeal mask airway for endotracheal intubation under vision: evaluation in 100 patients. Br J Anaesth 96:396–400.
3 Timmermann A, Russo S, Graf BM. (2006) Evaluation of the CTrachTM—an intubating LMA with integrated fibreoptic system. Br J Anaesth 96:516–21.
4 Baskett PJF, Parr MJA, Nolan JP. (1998) The intubating laryngeal mask: results of multicentre trial with experience of 500 cases. Anaesthesia 53:1174–9.[CrossRef][Web of Science][Medline]
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