134
| Correspondence
The disappearing art of intubation M. E. James Sheffield, UK E-mail: [email protected]
Declaration of interest None declared.
References 1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Karalapillai D, Darvall J, Mandeville J, et al. A review of video laryngoscopes relevant to the intensive care unit. Indian J Crit Care Med 2014; 18: 442–52 3. American College of Emergency Physicians. Letter from the Chair. Available from http://www.acep.org/Content.aspx? ID=100259 (accessed 4 February 2015) 4. Maharaj CH, Chonghaile M, Higgins BD, et al. Tracheal intubation by inexperienced medical residents using the Airtraq and Macintosh laryngoscopes—a manikin study. Am J Emerg Med 2006; 24: 769–74 5. Khan RM, Sharma PK, Kaul N. Airway management in trauma. Indian J Anaesth 2011; 55: 463–69 6. Hardwick WC, Bluhm D. Digital intubation. J Emerg Med 1984; 1: 317–20 7. Vacanti CA, Roberts JT. Blind oral intubation: the development and efficacy of a new approach. J Clin Anaesth 1992; 4: 399–401 8. Milligan KR, Kenny NT. Awake blind nasal intubation. Ulst Med J 1985; 54: 204–7 9. Bokhari A, Benham SW, Popat MT. Management of unanticipated difficult intubation: a survey of current practice in the Oxford region. Eur J Anaesth 2004; 21: 123–7 doi:10.1093/bja/aev190
The true cost of videolaryngoscopy may be trainee experience in fibreoptic intubation S. R. Dawson*, L. Taylor and P. Farling Belfast, UK *E-mail: [email protected]
Editor—We read with interest the article by Zaouter and colleagues1 on videolaryngoscopy (VL) as a new standard of care. In it they answer the question, ‘why are videolaryngoscopes not used for all tracheal intubations?’ by stating ‘It is only a cost issue.’ We suggest that this is incorrect and a valid reason would be loss of experience in fibreoptic intubation (FOI). It was our impression that with the advent of VL in our hospital the number of FOIs decreased. The operating department
technicians, whose duties include care of fibreoptic instruments, keep a written record of every FOI performed, including double lumen tube (DLT) checks. We analysed data from this source for two six-month periods before and after videolaryngoscopes became available. It showed that the number of FOIs decreased from 311 before videolaryngoscopes to 214 after their introduction. This constitutes a 31.2% reduction in usage (Table 1). The reduction was because of fewer asleep FOIs. This is to be expected
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on June 22, 2015
Editor—I read with interest the article by Zaouter and colleagues1 suggesting routine video laryngoscopy as a new standard of care. As a trainee, I have been exposed to and trained on a variety of video laryngoscopes and fibre-optic devices, of which there are an ever-increasing number.2 I have also worked in critical care departments whose first-choice laryngoscope is the McGRATH series 5 video laryngoscope, and it is evident there are similar tools becoming standard for everyday practice elsewhere.3 While these tools are easier for non-anaesthetic staff and junior anaesthetists to use, there are a number of potential pitfalls, least of which is their use in situations of the bleeding or heavily soiled airway.4 5 In these situations, the standard Macintosh blade would become the laryngoscope of choice. This raises the prospect of future generations of ‘airway experts’, who primarily use video laryngoscopes, lacking the experience to manage such situations and confidently achieve airway protection via direct laryngoscopy. The above scenario of the bleeding or soiled airway can be further complicated by a patient in whom optimal Cormack–Lehane views are unexpectedly III or IV. In such situations, techniques such as blind digital intubation and blind nasal intubation can serve as rescue methods, useful in multiple patient groups, including trauma and facial abscesses.5–8 These are skills that are largely in decline, and few would now attempt them in the emergent situation.9 Perhaps the desire to be pioneers may in fact hinder the advancement of safety in a small number of patients. Becoming competent with a broad range of techniques, including the rediscovery of some lost arts, may be the best way to maintain airway expertise and prevent our skills becoming ‘less refined’.
Correspondence
Table 1 Asleep vs awake FOI
| 135
Table 2 Indications for FOI. TMJ- temporomandibular joint January–June 2011
Number of asleep FOIs performed Number of awake FOIs performed
January–June 2014
258
158
53
56
Previous difficult intubation Poor mouth opening Poor TMJ movement Poor neck movement Trauma Abscess Tumour Congenital issues Unstable cervical spine DLT/ bronchoscopy
7.4
4.2
12.9 4.5 15.8 2.0 0.2 6.7 0.5 11.4 38.6
12.9 3.8 14.3 1.7 1.4 9.8 0 11.8 40.1
continue to be so, by embracing VL while continuing to develop the knowledge, skills and experience in FOI needed.
Declaration of interest None declared.
Funding
References 1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Royal College of Anaesthetists. Annex C- Intermediate Level Training 2010. Available from: http://www.rcoa.ac.uk/ system/files/TRG-CCT-ANNEXC_0.pdf (accessed 13 March 2015) doi:10.1093/bja/aev191
Videolaryngoscopy - for all intubations? R. Bulatovic* and R. Taneja Ontario, Canada *E-mail: [email protected]
Editor—We read with interest Dr Zaouter’s editorial on the evolving role of videolaryngoscopy in anaesthestic care.1 Overall we do agree with the authors that videolaryngoscopes will and should be available freely in the foreseeable future. As anaesthetists working in a teaching hospital, we already note that residents often choose these as their first-choice for laryngoscopy in anticipated difficult intubations. However, with increasing availability of new technology such as this, we must acknowledge that trainees will progressively lose their skills with conventional laryngoscopy. This may have safety implications for patients needing anaesthesia in remote locations where videolaryngoscopy may not be the norm. Hence, our younger colleagues, having to provide anaesthetic services
in such settings, may find themselves underprepared or unable to secure an airway. Furthermore, do not believe that videolaryngoscopes should be used for all intubations indiscriminately. Even though their use is associated with improved glottic visualization,2 the process of placing a tracheal tube takes longer and is more difficult with videolaryngoscopy.3 4 Thus, one might choose to perform a conventional laryngoscopy for a patient who needs rapid sequence induction (for an anticipated easy airway that has a high risk for aspiration). Additionally, reports exist of intubations which failed using videolaryngoscopy but were subsequently successful with direct laryngoscopy by the same operator.5 Pediatric intubations, which are challenging even for experienced
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on June 22, 2015
given that VL is indicated particularly where bag-mask ventilation is deemed possible, but intubation difficult. Table 2 shows that the greatest reduction in FOIs occurred in patients who were previously difficult to intubate and those with poor neck and jaw movement- patients in whom VL is indicated. The number of FOIs performed on patients with poor mouth opening remained unchanged- patients in whom awake FOI is indicated. This analysis supports our theory that the introduction of videolaryngoscopes accounted for the reduction in FOIs. Between 2011 and 2014 a new thoracic theatre was opened in our hospital. This is indicated by the slightly increased proportion of DLT checks. Apart from this theatre, lists and case mix remained largely unchanged. In conclusion, the introduction of videolaryngoscopes to our hospital has resulted in a 38.8% reduction in the number of asleep FOIs performed. VL is clearly an important part of the anaesthetist’s armamentarium when faced with a difficult airway. However, FOI provides a route to endotracheal intubation when VL is impossible. Thus it remains a core clinical learning outcome required of anaesthetic trainees by the Royal College of Anaesthetists.2 We have shown that when VL becomes available, training opportunities with FOI markedly decrease. It is therefore incumbent upon us to recognize this and ensure that training and experience with FOI does not suffer. As the authors rightly state ‘we have always been pioneers in patients’ safety’. Let us
2011 Proportion 2014 Proportion of cases (%) of cases (%)
| Correspondence
The disappearing art of intubation M. E. James Sheffield, UK E-mail: [email protected]
Declaration of interest None declared.
References 1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Karalapillai D, Darvall J, Mandeville J, et al. A review of video laryngoscopes relevant to the intensive care unit. Indian J Crit Care Med 2014; 18: 442–52 3. American College of Emergency Physicians. Letter from the Chair. Available from http://www.acep.org/Content.aspx? ID=100259 (accessed 4 February 2015) 4. Maharaj CH, Chonghaile M, Higgins BD, et al. Tracheal intubation by inexperienced medical residents using the Airtraq and Macintosh laryngoscopes—a manikin study. Am J Emerg Med 2006; 24: 769–74 5. Khan RM, Sharma PK, Kaul N. Airway management in trauma. Indian J Anaesth 2011; 55: 463–69 6. Hardwick WC, Bluhm D. Digital intubation. J Emerg Med 1984; 1: 317–20 7. Vacanti CA, Roberts JT. Blind oral intubation: the development and efficacy of a new approach. J Clin Anaesth 1992; 4: 399–401 8. Milligan KR, Kenny NT. Awake blind nasal intubation. Ulst Med J 1985; 54: 204–7 9. Bokhari A, Benham SW, Popat MT. Management of unanticipated difficult intubation: a survey of current practice in the Oxford region. Eur J Anaesth 2004; 21: 123–7 doi:10.1093/bja/aev190
The true cost of videolaryngoscopy may be trainee experience in fibreoptic intubation S. R. Dawson*, L. Taylor and P. Farling Belfast, UK *E-mail: [email protected]
Editor—We read with interest the article by Zaouter and colleagues1 on videolaryngoscopy (VL) as a new standard of care. In it they answer the question, ‘why are videolaryngoscopes not used for all tracheal intubations?’ by stating ‘It is only a cost issue.’ We suggest that this is incorrect and a valid reason would be loss of experience in fibreoptic intubation (FOI). It was our impression that with the advent of VL in our hospital the number of FOIs decreased. The operating department
technicians, whose duties include care of fibreoptic instruments, keep a written record of every FOI performed, including double lumen tube (DLT) checks. We analysed data from this source for two six-month periods before and after videolaryngoscopes became available. It showed that the number of FOIs decreased from 311 before videolaryngoscopes to 214 after their introduction. This constitutes a 31.2% reduction in usage (Table 1). The reduction was because of fewer asleep FOIs. This is to be expected
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on June 22, 2015
Editor—I read with interest the article by Zaouter and colleagues1 suggesting routine video laryngoscopy as a new standard of care. As a trainee, I have been exposed to and trained on a variety of video laryngoscopes and fibre-optic devices, of which there are an ever-increasing number.2 I have also worked in critical care departments whose first-choice laryngoscope is the McGRATH series 5 video laryngoscope, and it is evident there are similar tools becoming standard for everyday practice elsewhere.3 While these tools are easier for non-anaesthetic staff and junior anaesthetists to use, there are a number of potential pitfalls, least of which is their use in situations of the bleeding or heavily soiled airway.4 5 In these situations, the standard Macintosh blade would become the laryngoscope of choice. This raises the prospect of future generations of ‘airway experts’, who primarily use video laryngoscopes, lacking the experience to manage such situations and confidently achieve airway protection via direct laryngoscopy. The above scenario of the bleeding or soiled airway can be further complicated by a patient in whom optimal Cormack–Lehane views are unexpectedly III or IV. In such situations, techniques such as blind digital intubation and blind nasal intubation can serve as rescue methods, useful in multiple patient groups, including trauma and facial abscesses.5–8 These are skills that are largely in decline, and few would now attempt them in the emergent situation.9 Perhaps the desire to be pioneers may in fact hinder the advancement of safety in a small number of patients. Becoming competent with a broad range of techniques, including the rediscovery of some lost arts, may be the best way to maintain airway expertise and prevent our skills becoming ‘less refined’.
Correspondence
Table 1 Asleep vs awake FOI
| 135
Table 2 Indications for FOI. TMJ- temporomandibular joint January–June 2011
Number of asleep FOIs performed Number of awake FOIs performed
January–June 2014
258
158
53
56
Previous difficult intubation Poor mouth opening Poor TMJ movement Poor neck movement Trauma Abscess Tumour Congenital issues Unstable cervical spine DLT/ bronchoscopy
7.4
4.2
12.9 4.5 15.8 2.0 0.2 6.7 0.5 11.4 38.6
12.9 3.8 14.3 1.7 1.4 9.8 0 11.8 40.1
continue to be so, by embracing VL while continuing to develop the knowledge, skills and experience in FOI needed.
Declaration of interest None declared.
Funding
References 1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Royal College of Anaesthetists. Annex C- Intermediate Level Training 2010. Available from: http://www.rcoa.ac.uk/ system/files/TRG-CCT-ANNEXC_0.pdf (accessed 13 March 2015) doi:10.1093/bja/aev191
Videolaryngoscopy - for all intubations? R. Bulatovic* and R. Taneja Ontario, Canada *E-mail: [email protected]
Editor—We read with interest Dr Zaouter’s editorial on the evolving role of videolaryngoscopy in anaesthestic care.1 Overall we do agree with the authors that videolaryngoscopes will and should be available freely in the foreseeable future. As anaesthetists working in a teaching hospital, we already note that residents often choose these as their first-choice for laryngoscopy in anticipated difficult intubations. However, with increasing availability of new technology such as this, we must acknowledge that trainees will progressively lose their skills with conventional laryngoscopy. This may have safety implications for patients needing anaesthesia in remote locations where videolaryngoscopy may not be the norm. Hence, our younger colleagues, having to provide anaesthetic services
in such settings, may find themselves underprepared or unable to secure an airway. Furthermore, do not believe that videolaryngoscopes should be used for all intubations indiscriminately. Even though their use is associated with improved glottic visualization,2 the process of placing a tracheal tube takes longer and is more difficult with videolaryngoscopy.3 4 Thus, one might choose to perform a conventional laryngoscopy for a patient who needs rapid sequence induction (for an anticipated easy airway that has a high risk for aspiration). Additionally, reports exist of intubations which failed using videolaryngoscopy but were subsequently successful with direct laryngoscopy by the same operator.5 Pediatric intubations, which are challenging even for experienced
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on June 22, 2015
given that VL is indicated particularly where bag-mask ventilation is deemed possible, but intubation difficult. Table 2 shows that the greatest reduction in FOIs occurred in patients who were previously difficult to intubate and those with poor neck and jaw movement- patients in whom VL is indicated. The number of FOIs performed on patients with poor mouth opening remained unchanged- patients in whom awake FOI is indicated. This analysis supports our theory that the introduction of videolaryngoscopes accounted for the reduction in FOIs. Between 2011 and 2014 a new thoracic theatre was opened in our hospital. This is indicated by the slightly increased proportion of DLT checks. Apart from this theatre, lists and case mix remained largely unchanged. In conclusion, the introduction of videolaryngoscopes to our hospital has resulted in a 38.8% reduction in the number of asleep FOIs performed. VL is clearly an important part of the anaesthetist’s armamentarium when faced with a difficult airway. However, FOI provides a route to endotracheal intubation when VL is impossible. Thus it remains a core clinical learning outcome required of anaesthetic trainees by the Royal College of Anaesthetists.2 We have shown that when VL becomes available, training opportunities with FOI markedly decrease. It is therefore incumbent upon us to recognize this and ensure that training and experience with FOI does not suffer. As the authors rightly state ‘we have always been pioneers in patients’ safety’. Let us
2011 Proportion 2014 Proportion of cases (%) of cases (%)
