If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
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E-letters: Electronic letters published:
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Rapidly enlarging growths: Anesthesists beware
- Rajeev Sharma (14 October 2008)
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Preservation of Airway Skills
- Anna R Walton, Anna Fowler, Sameer Khemani (10 October 2008)
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Glidescope for Laryngoscopy: Is it the learning curve or the technique?
- Mary Kristine Bonn, Santhanam Suresh, MD FAAP (10 October 2008)
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Rajeev Sharma, Ex-Senior Resident Department of Anesthesia, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
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Dear Sir, I read with interest "Preservation of Airway Skills". The case described here was a challenging one. I have few reservations againt the airway management; The patient presented with an anticipated difficult airway with known sarcoma of the left pyriform fossa and stridor and Flexible nasendoscopy showed extensive left-sided supra-glottic tumour involvement. The presenting complaint was stridor. The authors have mentioned that previous airway management was easy. (1) They need to document the time interval in between the two anesthetics. (2) Did the patient present with stridor at previous anesthetic. It seems unlikely ,otherwise tracheostomy would have been performed previously. (3) In presence of stridor and a documented airway difficulty; it is unsafe to proceed with attempts of intubation after i.v induction and muscle paralysis as was performed in the presented case. (4) In rapidly enlarging tumors, a previously uneventful airway management gives a false sense of security to the anesthesists as justified in the presented case. (5) I suggest that the above are also basic skills that an anesthesist should never forget during airway management. Conflict of Interest:None declared |
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Anna R Walton, Specialist Registrar Royal National Throat, Nose and Ear Hospital, Grays Inn Road, London, Anna Fowler, Sameer Khemani
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We are interested to note the number of articles and letters highlighting the increasing use of video laryngoscopes. In particular we were interested to learn that in paediatric patients, improved laryngoscopy with a video laryngoscope did not lead to more rapid tracheal intubation.1 Abnormal laryngeal anatomy is an important cause of difficult laryngoscopy and difficult intubation, and anaesthetists may be tempted to abandon traditional laryngosopy techniques in favour of video laryngoscopy. We present a case where a the trachea of a patient with difficult laryngoscopy was intubated successfully using classical techniques, where video laryngoscopy failed. A 62 year old woman with known sarcoma of the left pyriform fossa and stridor was scheduled for semi-elective tracheostomy. View ImageFlexible nasendoscopy showed extensive left-sided supra-glottic tumour involvement. Review of previous anaesthetic charts revealed that bag-valve-mask ventilation had been easy, with grade 2 laryngoscopy with a standard Mackintosh blade and tracheal intubation had been achieved over a bougie. Anticipating difficult laryngoscopy and intubation, a range of airway adjuncts was available, and she was anaesthetised in theatre with ENT surgeons standing by, prepared to perform emergency trachesostomy if necessary. Anaesthesia was induced intravenously with fentanyl and propofol and muscle relaxation was achieved with atracurium. Face-mask ventilation was easy. Laryngoscopy was attempted with the Airtraq Laryngoscope to reveal very abnormal laryngeal anatomy and a laryngeal inlet which was almost completely obscured by a now greatly enlarged tumour. Attempts to insert an endo-tracheal tube over a bougie were unsuccessful, resulting in two oesophageal intubations. The view obtained with a straight-bladed laryngoscope was inadequate. Eventually, laryngoscopy was performed using a McCoy laryngoscope, which lifted the epiglottis sufficiently to allow successful intubation using a gum elastic bougie. Surgery then proceeded uneventfully. This case highlights the fact that it is critical to maintain core skills in airway management, laryngoscopy and intubation. The reduction in trainees’ hours and increased use of supraglottic airway devices further decrease exposure to tracheal intubation. Successful intubation is most likely to be achieved using devices with which one is most familiar, and there is undoubtedly a learning curve with new equipment. Video laryngoscopes may improve visualisation of the larynx, but may not necessarily make intubation easier. It also may be the case that video laryngoscopes have a very important place in difficult laryngoscopy with a normal larynx, but that in cases such as this where laryngeal anatomy is abnormal, their role is limited. A.R Walton A. Fowler S. Khemani Royal National Throat Nose and Ear Hospital, Grays Inn Road, London E-mail: awalton@doctors.org.uk References 1. Kim JT, Na HS, Bae JY et al. GlideScope® video laryngoscope: a randomised clinical trial in 203 paediatric patients. Br J Anaesth 2008; 101 (4): 531-4 Conflict of Interest:None declared |
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Mary Kristine Bonn, Resident in Anesthesiology Children's Memorial Hospital, Northwestern University's Feinberg School of Medicine, Santhanam Suresh, MD FAAP
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We read with interest you article comparing the glidescope to a regular laryngoscopy blade in children. Our experience has been similar to yours. Although visualization of the glottis has been adequate, it is harder to pass the endotracheal tube in children. This may be related to the Glidescope being larger and more bulky compared to a regular laryngoscope blade. This may also be related to our relative inexperience with the Glidescope. Previous studies have demonstrated improved skills with repeated use of fiberoptic scopes for intubation in teaching institutions. This article should encourage more pediatric anesthesiologists to utilize the Glidescope and get comfortable with its use. Moreover, if attempts are made to reduce the size of the blade, this may allow us to use the Glidescope more frequently for difficult intubations. Conflict of Interest:None declared |
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