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Re: Scuring airway in patients with restricted neck mobility
- Ryu Komatsu, Kotoe Kamata, Ikue Hoshi, Daniel I. Sessler, and Makoto Ozaki (12 March 2009)
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Scuring airway in patients with restricted neck mobility
- Anju Gupta, nishkarsh Gupta, Rakesh Garg (10 January 2009)
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Ryu Komatsu , Kotoe Kamata, Ikue Hoshi, Daniel I. Sessler, and Makoto Ozaki
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Reply: We agree with the reviewers’ comment that manual inline stabilization (MILS) is more efficient than a rigid collar when it comes to preventing cervical-spine movement during airway management. A description of this has been incorporated in the introduction of another manuscript.1 But our study design did not seek the best methods of stabilization. We did not indicate that we were attempting to manage patients with possible cervical spine injuries. Rather we restricted the patients with rigid collars because we knew this would reduce the mouth opening and make laryngoscopy difficult. A suboptimal laryngeal view (i.e. modified Cormack-Lehane grade 3a or above) was necessary for our study. Regarding second point, Enomoto et al.2 described the use of the Airway Scope in patients whose necks were stabilized with MILS and in his study, intubation time with the Airway Scope was 54 ± 14 sec (mean ± SD) This was slower than the mean intubation times recorded for the current study. In particular, even if the mouth opening was as small as 2 cm and approached the thickness of the Intlock (1.8 cm), the authors found that insertion of the Intlock into the hypopharynx and subsequent visualization of the larynx, was not difficult when using the Airway Scope. We were able to see the glottis for each patient in the scope’s crosshairs. This might explain why Airway Scope intubation in patients wearing a collar was no slower than intubation in patients whose necks were stabilized with MILS. However, it is known that use of a rigid collar results in a poor laryngeal view more frequently than MILS,1-3 and thereby presumably makes intubation with the GEB more difficult and time consuming than those with MILS. Gupta et al stated that a 15-second difference in intubation time between the two methods is only marginally significant, even when patients are already hypoxic from an emergency situation. In our study, the median time for the Aiway Scope was 30 seconds and intubation took 40 seconds using the GEB. But, the true aim of the study was not the intubation time, but the success rate of intubation. No failed intubations occurred when using the Airway Scope, which may be attributed to the unobstructed view of the glottis. The thyromantal distances may have appeared long because the patient’s neck was extended maximally during measurement of thyromental distance. The subjects in the current study were all Asians, who have considerably smaller heights and weights than a Caucasion population. Therefore, one might speculate that in a Caucasion population, the cause of intubation failure might be due to an inappropriate length of Intlock. Point 3: At this time, an Airway Scope costs $6000, which is a lower cost than when the product became commercially available in 2006. As one would expect with any new device, the retail price will presumably continue to decrease in the future. The cost of the instrument may eventually be offset by the success rate of intubation, particularly in patients with a limited mouth opening. Point 4: The Intlock part which covers the camera lens never makes direct contact with mucosal tissue. This is because the camera lens is located posterior to the device’s tip. The views using the Airway Scope were therefore not obstructed by small amounts of blood or secretion. References 1. Komatsu R, Kamata K, Hamada K, Sessler DI, Ozaki M. Airway scope and StyletScope for tracheal intubation in a simulated difficult airway. Anesth Analg 2009; 108: 273-9 2. Enomoto Y, Asai T, Arai T, Kamishima K, Okuda Y. Pentax-AWS, a new videolaryngoscope, is more effective than the Macintosh laryngoscope for tracheal intubation in patients with restricted neck movements: a randomized comparative study. Br J Anaesth 2008; 100: 544-8 3. Komatsu R, Kamata K, Hoshi I, Sessler DI, Ozaki M. Airway scope and gum elastic bougie with Macintosh laryngoscope for tracheal intubation in patients with simulated restricted neck mobility. Br J Anaesth 2008; 101: 863-9 Conflict of Interest:None declared |
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Anju Gupta, Junior specialst government of NCT , Delhi, nishkarsh Gupta, Rakesh Garg
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Title: Airway securing concerns in patient with restricted neck mobility with newer gadgets like airway scope. Authors: Nishkarsh gupta, Rakesh Garg, Anju gupta, Corresponding Author: Dr. Anju Gupta MBBS, MD, DNB, MNAMS(Anaesthesia) Junior specialist, government of NCT Delhi Email: dranjugupta2009@rediffmail.com Other authors: Dr. Nishkarsh Gupta MBBS, MD, DNB, MNAMS (Anaesthesia) Attending Consultant, Max hospital, Saket, Delhi Dr. Rakesh Garg MBBS, MD, DNB, MNAMS (Anaesthesia) Senior resident, AIIMS, Delhi We read with great interest the study by komatsu et al 1“Airway Scope and gum elastic bougie with Macintosh laryngoscope for tracheal intubation in patients with simulated restricted neck mobility”. Although they have provided a great deal of valuable information but we would urge great caution in the interpretation of results and their extrapolation to any clinical setting. Firstly authors have created cervical spine immobility with rigid collar. Maker nick has demonstrated manual inline stabilization (MILI) is betted than collar in reducing cervical spine movement during intubation.2 Moreover collars reduce mouth opening and make laryngoscopy difficult.3 Authors also have reported mouth opening of 2 cm with the use of cervical collar which probably has decreased the successful intubations and increased the intubation time with bougie (34 s with airway scope vs 49 s with bougie). Moreover, though the difference in intubation time is statistically significant but its clinical importance needs to be considered (time difference of 15 sec within mean time of 49 sec in the bougie group). Also it will be more informative if the median time for intubation be mentioned by the authors rather than the mean time. We firmly believe, the effectiveness of airway scope with respect to bougie would have been reduced if MILI was used rather than cervical collar. Secondly the airway scope blade ( INTLOCK) comes in only one size and there are reports of failure of intubation with it in patients with long neck.4 It is surprising the authors did not have any failure with the device despite average TMD 8.7 cm in the group. Thirdly airway scope is very costly as compared to gum elastic bougie (6000 $ vs 80$). 1 Fourthly, the trauma victims requiring neck stabilization may usually be associated with facial and oral trauma. The use of Airway scope will be limited in case of oral bleeding or secretion as the view will be obscured by them. Hence its use will be restricted in true emergency scenario. Considering the limitation of sizes of INTLOCK, nonavailability in emergency settings and high cost associated with the use of Airway scope, its clinical use is limited. We think that it will be worth mentioning the role of Airway scope in the clinical scenario with restricted mouth opening like temporomandibular joint ankylosis, if the mouth opening is adequate to permit its entry. References 1. R. Komatsu, K. Kamata, I. Hoshi, D. I. Sessler, and M. Ozaki. Airway Scope and gum elastic bougie with Macintosh laryngoscope for tracheal intubation in patients with simulated restricted neck mobility. Br. J. Anaesth. 2008 101: 863- 869 2.Majernick TG, bieniek R, Houstan JB, Hughes HG. Cervical spine movement during Orotracheal intubation. Ann Emerg Med 1986; 15: 417-20 3.Heath KJ. The effect of laryngoscopy on different cervical spine immobilization techniques. Anaesthesia 1994; 49: 843-45. 4.Nobuko Sasano, Hiroki Yamauchi, and Yoshihito Fujita. Failure of the Airway Scope to reach the larynx. Can J Anesth 2007 54: 774-775. Conflict of Interest:None declared |
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