Correspondence
Anaesthesia 2014, 69, 785–798
D. G. Maloney C. Hinchcliffe R. M. Knights J. D. Walker Ysbyty Gwynedd, Bangor, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Kelly FE, Hardy R, Hall EA, et al. Fire on an intensive care unit caused by an oxygen cylinder. Anaesthesia 2013; 68: 102–4. 2. Kelly FE, Hardy R, Henrys P. Oxygen cylinder fire – an update. Anaesthesia 2014; 69: 511–3. doi:10.1111/anae.12749
Extended roles for videolayngoscopy Montague and colleagues describe use of the Glidescopeâ (Verathon Medical United Kingdom Ltd., High Wycombe, UK) to guide placement of nasopharyngeal airways and balloon catheters visually in patients having cleft palate surgery [1]. As well as facilitating tracheal intubation, we have used videolaryngoscopy during facial reconstructive surgery for the extensive facial deformity and scarring caused by noma (cancrum oris), in survivors presenting to the Facing Africa charity in Ethiopia (see www.facing africa.org). Intubation in patients affected by noma is complicated by significant midface defects, restricted mouth opening with trismus [2],
and risk of airway compromise and soiling during microvascular free flap surgery. We use either the Glidescope or the McGrath MACâ (Aircraft Medical, Edinburgh, UK) to inspect the airway routinely after surgery and guide oropharyngeal suction, and find this technique consistently to be more effective than ‘blind’ suction and less stimulating than using direct laryngoscopy [3]. Similarly, videolaryngoscopy enables nasogastric feeding tube placement under direct vision. We commend these extended roles for videolayngoscopy for use by colleagues in the wider general surgical population. J. K. Gordon Sheffield Teaching Hospitals, Sheffield, UK Email: [email protected] G. Rodney Ninewells Hospital, Dundee, UK D. R. Ball Dumfries and Galloway Royal Infirmary, Dumfries, UK The Glidescope is supplied to the charity by Verathon Medical and the Mcgrath MAC by Aircraft Medical. Previously posted on the Anaesthesia correspondence website: www.anaes thesiacorrespondence.com.
References 1. Montague J, Cadier M, Williams S. Novel uses of the Glidescopeâ in cleft palate surgery. Anaesthesia 2014; 69: 393. 2. Coupe M, Johnson D, Seigne P, Hamlin B. Airway management in reconstructive surgery for Noma (cancrum oris). Anesthesia and Analgesia 2013; 117: 211–8. 3. Popat M, Mitchell V, Dravid R, Patel A, Swampilli C, Higgs A. Difficult Airway Society guidelines for the management
© 2014 The Association of Anaesthetists of Great Britain and Ireland
of extubation. Anaesthesia 2012; 67: 318–22. doi:10.1111/anae.12757
Teaching fibreoptic bronchoscopy using smart phones Smart devices are becoming increasing popular for teaching airway skills with a number of applications (‘apps’) and adaptors becoming available [1, 2]. We have found that the performance of an iPhoneâ (Apple Inc., Cupertino, CA, USA)modified fibreoptic bronchoscope compares well with an unmodified fibreoptic bronchoscope, and could provide a low-cost solution for teaching fibreoptic airway skills [3]. There are many advantages for using smart devices to teach airway skills. Compared with traditional video stacks, phones, phablets, pads and tablets [4] are relatively cheap, portable and don’t require external power supplies or light sources. High-quality camera optics enable rea-time image acquisition, storage, manipulation and transmission via a spectrum of wireless technologies including Bluetooth, NFC (near field communication), WiFi, and 3G. Images can also be transmitted to larger screens in theatre for teaching purposes, intra-operative assessment in the case of shared airway surgery or streamed via third party applications to other smart devices (Fig. 3) or websites. Virtual simulation software has reportedly been useful for teaching fibreoptic and neonatal intubation skills [5]. 793
Anaesthesia 2014, 69, 785–798
Correspondence
Figure 3 Image of manikin larynx aperture streamed from an iPhone attached to a fibreoptic bronchoscope to an iPad. Adopting smart device technologies to teach airway skills comes with significant concerns. Foremost is patient confidentiality. Images could potentially find their way on to social media websites resulting in a breach of patient privacy, potential identify theft and litigation. Novel devices within the operating theatre may be distracting, leading to potential drug errors or other adverse events resulting from inattention. The device may contaminate the surgical field, become a vector for the transmission of nosocomial infections or potentially interfere with electrical equipment such as infusion pumps or ventilators. Medical applications developed by non-medical vendors may cause patient harm if not appropriately reviewed or regulated [6]. The use of manikins to simulate difficulty airway scenarios is widespread in anaesthesia; however, there is little evidence that these studies correlate with clinical performance [7]. In our comparison, we used an Eye Scope mobile phone zoom lens-enabled iPhone 4.0 connected to the eyepiece of the flexible fibreoptic bronchoscope using a white rubber door stop (an adaptor 794
and software has become commercially available [2]). Our device was simple, inexpensive, did not require additional software and could be modified for use with a range of smart devices by incorporating the lens attachment into any plastic backing for a particular device. However, we found that the weight and length of the modification made intubation more difficult compared with the unmodified scope. Whether these devices are clinically useful or are just another novelty or marketing tool remains to be determined. A. Langley G. Mar Fan Queen Elizabeth II Jubilee Hospital, Brisbane, Australia Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. De Oliveira GS, Glassenberg R, Chang R, et al. Virtual airway simulation to improve dexterity among novices performing fibreoptic intubation. Anaesthesia 2013; 68: 1053–8.
2. Endoscope-i. Endoscopic mobile imaging, 2014. http://endoscope-i.com/ adapters.html (accessed 25/03/ 2014). 3. Langley A, Mar Fan G. Comparison of the Glidescope, flexible fibreoptic intubating bronchoscope, iPhone modified bronchoscope, and the Macintosh laryngoscope in normal and difficult airways: a manikin study. BMC Anesthesiology 2014; 14: 10. 4. Low D, Goos M. Using an Apple iPadTM to assist fibreoptic intubation. Anaesthesia 2013; 68: 110–1. 5. Hawkes CP, Hanotin S, OFlaherty B, et al. Using smart phone technology to teach neonatal endotracheal intubation (NeoTube): application development and uptake. Acta Paediatrica 2012; 101: e134–6. 6. Rodrigues MA, Brady RR. Anaesthetists and apps: content and contamination concerns. Anaesthesia 2011; 66: 1184–5. 7. Rai MR, Popat MT. Evaluation of airway equipment: man or manikin? Anaesthesia 2011; 66: 1–3. doi:10.1111/anae.12768
Efficacy of one-handed ventilation techniques We read with interest the article by Russo et al. [1] comparing ventilation by, and skill transfer in, novice users via either a facemask or an LMA Supreme in a manikin, and the accompanying letter [2]. We agree with Nielsen’s call for the use of uniform and objective methods in research and clinical practice when assessing that most basic aspect of airway management, namely onehanded facemask ventilation, which Russo and Nielsen highlight as currently ‘rudimentary’, arising from a general lack of understanding of the conventional technique involved. Unlike the airway manoeuvres originally described for expired air ventilation during cardiopulmonary resuscitation by Safar and Elam in the 1950s, single-handed facemask
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2014, 69, 785–798
D. G. Maloney C. Hinchcliffe R. M. Knights J. D. Walker Ysbyty Gwynedd, Bangor, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Kelly FE, Hardy R, Hall EA, et al. Fire on an intensive care unit caused by an oxygen cylinder. Anaesthesia 2013; 68: 102–4. 2. Kelly FE, Hardy R, Henrys P. Oxygen cylinder fire – an update. Anaesthesia 2014; 69: 511–3. doi:10.1111/anae.12749
Extended roles for videolayngoscopy Montague and colleagues describe use of the Glidescopeâ (Verathon Medical United Kingdom Ltd., High Wycombe, UK) to guide placement of nasopharyngeal airways and balloon catheters visually in patients having cleft palate surgery [1]. As well as facilitating tracheal intubation, we have used videolaryngoscopy during facial reconstructive surgery for the extensive facial deformity and scarring caused by noma (cancrum oris), in survivors presenting to the Facing Africa charity in Ethiopia (see www.facing africa.org). Intubation in patients affected by noma is complicated by significant midface defects, restricted mouth opening with trismus [2],
and risk of airway compromise and soiling during microvascular free flap surgery. We use either the Glidescope or the McGrath MACâ (Aircraft Medical, Edinburgh, UK) to inspect the airway routinely after surgery and guide oropharyngeal suction, and find this technique consistently to be more effective than ‘blind’ suction and less stimulating than using direct laryngoscopy [3]. Similarly, videolaryngoscopy enables nasogastric feeding tube placement under direct vision. We commend these extended roles for videolayngoscopy for use by colleagues in the wider general surgical population. J. K. Gordon Sheffield Teaching Hospitals, Sheffield, UK Email: [email protected] G. Rodney Ninewells Hospital, Dundee, UK D. R. Ball Dumfries and Galloway Royal Infirmary, Dumfries, UK The Glidescope is supplied to the charity by Verathon Medical and the Mcgrath MAC by Aircraft Medical. Previously posted on the Anaesthesia correspondence website: www.anaes thesiacorrespondence.com.
References 1. Montague J, Cadier M, Williams S. Novel uses of the Glidescopeâ in cleft palate surgery. Anaesthesia 2014; 69: 393. 2. Coupe M, Johnson D, Seigne P, Hamlin B. Airway management in reconstructive surgery for Noma (cancrum oris). Anesthesia and Analgesia 2013; 117: 211–8. 3. Popat M, Mitchell V, Dravid R, Patel A, Swampilli C, Higgs A. Difficult Airway Society guidelines for the management
© 2014 The Association of Anaesthetists of Great Britain and Ireland
of extubation. Anaesthesia 2012; 67: 318–22. doi:10.1111/anae.12757
Teaching fibreoptic bronchoscopy using smart phones Smart devices are becoming increasing popular for teaching airway skills with a number of applications (‘apps’) and adaptors becoming available [1, 2]. We have found that the performance of an iPhoneâ (Apple Inc., Cupertino, CA, USA)modified fibreoptic bronchoscope compares well with an unmodified fibreoptic bronchoscope, and could provide a low-cost solution for teaching fibreoptic airway skills [3]. There are many advantages for using smart devices to teach airway skills. Compared with traditional video stacks, phones, phablets, pads and tablets [4] are relatively cheap, portable and don’t require external power supplies or light sources. High-quality camera optics enable rea-time image acquisition, storage, manipulation and transmission via a spectrum of wireless technologies including Bluetooth, NFC (near field communication), WiFi, and 3G. Images can also be transmitted to larger screens in theatre for teaching purposes, intra-operative assessment in the case of shared airway surgery or streamed via third party applications to other smart devices (Fig. 3) or websites. Virtual simulation software has reportedly been useful for teaching fibreoptic and neonatal intubation skills [5]. 793
Anaesthesia 2014, 69, 785–798
Correspondence
Figure 3 Image of manikin larynx aperture streamed from an iPhone attached to a fibreoptic bronchoscope to an iPad. Adopting smart device technologies to teach airway skills comes with significant concerns. Foremost is patient confidentiality. Images could potentially find their way on to social media websites resulting in a breach of patient privacy, potential identify theft and litigation. Novel devices within the operating theatre may be distracting, leading to potential drug errors or other adverse events resulting from inattention. The device may contaminate the surgical field, become a vector for the transmission of nosocomial infections or potentially interfere with electrical equipment such as infusion pumps or ventilators. Medical applications developed by non-medical vendors may cause patient harm if not appropriately reviewed or regulated [6]. The use of manikins to simulate difficulty airway scenarios is widespread in anaesthesia; however, there is little evidence that these studies correlate with clinical performance [7]. In our comparison, we used an Eye Scope mobile phone zoom lens-enabled iPhone 4.0 connected to the eyepiece of the flexible fibreoptic bronchoscope using a white rubber door stop (an adaptor 794
and software has become commercially available [2]). Our device was simple, inexpensive, did not require additional software and could be modified for use with a range of smart devices by incorporating the lens attachment into any plastic backing for a particular device. However, we found that the weight and length of the modification made intubation more difficult compared with the unmodified scope. Whether these devices are clinically useful or are just another novelty or marketing tool remains to be determined. A. Langley G. Mar Fan Queen Elizabeth II Jubilee Hospital, Brisbane, Australia Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. De Oliveira GS, Glassenberg R, Chang R, et al. Virtual airway simulation to improve dexterity among novices performing fibreoptic intubation. Anaesthesia 2013; 68: 1053–8.
2. Endoscope-i. Endoscopic mobile imaging, 2014. http://endoscope-i.com/ adapters.html (accessed 25/03/ 2014). 3. Langley A, Mar Fan G. Comparison of the Glidescope, flexible fibreoptic intubating bronchoscope, iPhone modified bronchoscope, and the Macintosh laryngoscope in normal and difficult airways: a manikin study. BMC Anesthesiology 2014; 14: 10. 4. Low D, Goos M. Using an Apple iPadTM to assist fibreoptic intubation. Anaesthesia 2013; 68: 110–1. 5. Hawkes CP, Hanotin S, OFlaherty B, et al. Using smart phone technology to teach neonatal endotracheal intubation (NeoTube): application development and uptake. Acta Paediatrica 2012; 101: e134–6. 6. Rodrigues MA, Brady RR. Anaesthetists and apps: content and contamination concerns. Anaesthesia 2011; 66: 1184–5. 7. Rai MR, Popat MT. Evaluation of airway equipment: man or manikin? Anaesthesia 2011; 66: 1–3. doi:10.1111/anae.12768
Efficacy of one-handed ventilation techniques We read with interest the article by Russo et al. [1] comparing ventilation by, and skill transfer in, novice users via either a facemask or an LMA Supreme in a manikin, and the accompanying letter [2]. We agree with Nielsen’s call for the use of uniform and objective methods in research and clinical practice when assessing that most basic aspect of airway management, namely onehanded facemask ventilation, which Russo and Nielsen highlight as currently ‘rudimentary’, arising from a general lack of understanding of the conventional technique involved. Unlike the airway manoeuvres originally described for expired air ventilation during cardiopulmonary resuscitation by Safar and Elam in the 1950s, single-handed facemask
© 2014 The Association of Anaesthetists of Great Britain and Ireland
