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Time for endotracheal intubation
- Davide Cattano (28 September 2009)
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Davide Cattano, Assistant Prof of Anesthesiology University of Texas Houston Medical School
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Dear editor, I read with interest the large cohort analysis of the Danish Anaesthesia Database for difficult tracheal intubation by Lundstrom and collegues [1]. It has been notoriously confirmed that the incidence of a difficult endotracheal intubation by direct laryngoscopy is set at 5% and this study confirmed the data on a vast population. They described the frequencies of DTI been falling from 5.8 to 5.1% and the failed intubation set at 0.27%. However almost 3% of the patients were escluded from the analysis because of flexible fibreoptic intubation. The study aimed to describe the role of neuromuscular blockade for facilitationg endotracheal intubation conditions. As the authors stated, there has been a trend to avoid the use of muscle relaxants and this practice may have led to an increased 25% chance of difficult conditions (is it really significant) for elective surgeries and almost 300% percent increased chance in emergency situations. The study is missing however informations that would make a difference: the time and the quality of relaxation and the drug used for inducing general anesthesia. The increase of no use of NMBA was on the use of non depolarizing agents, while a decrease in the total number of DTI has been recorded. Moreover the common use of depolarizing agents has maintained a close proportion, meaning that sick, obese and emergency surgery will be treated with the precautions that are needed and the reason to use muscle relaxation for quicker and better intubation conditions. The last point I am raising relates to the importance of a routine airway evaluation. Despite several issues affect predictability of the difficult airway, the assessment of factors such as neck position, mouth opening, tissues complaince and the emergency of the procedure would still direct the anesthesiologist towards the proper technique. In conclusion it is difficult in my opinion to generalize based on the data presented by our danish collegues if muscle relaxation avoidance is clinical significant of an increase in difficult endotracheal intubations in elective conditions. Sincerely Davide Cattano, MD, PhD Assistant Professor of Anesthesiology UTHSC-Houston Medical School Houston TX [1] Lundstrom LH, Moller AM, Rosenstock C et al. Avoidance of neuromuscular blocking agents may increase the risk of difficult tracheal intubation: a cohort study of 103812 consecutive adult patients recorded in the Danish Anaesthesia Database. BJA 2009, 103: 283-90 Conflict of Interest:None declared |
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