Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults: Need to be revisited?: Reply

Abstract

We read with much interest the special article by Frerk and colleagues 1 about recent updated guidelines on the management of unanticipated difficult intubation in adults. The article appears to be very informative and assists in decision making. The authors described use of the scalpel-finger-bougie technique in case of impalpable cricothyroid membrane and suggested a midline vertical skin incision of 8-10 cm directed caudad to cephalad. We found an 8-10 cm length of incision over the trachea to be quite debatable, as it can lead to higher risk of bleeding/oozing from the local tissues making poor visualization of landmarks and risk of infection postoperatively. However, it can help in better palpation of the cricothyroid membrane. 2 We suggest the authors should acknowledge the use of techniques such as infiltration of local anaesthetic along with epinephrine, or the standby measures such as application of cautery (monopolar/bipolar), to stop bleeding at the local site while performing the procedure in an emergency.

Comparing success rates of anesthesia providers versus trauma surgeons in their use of palpation to identify the cricothyroid membrane in female subjects: a prospective observational study

“…Our recommendations are consistent with the most recent "Difficult Airway Society guidelines for management of unanticipated difficult intubation in adults". 27 In conclusion, this study adds several important findings to the current literature. First, the success rate of both anesthesia providers and trauma surgeons for identifying CTM by palpation was ≤ 50%, even in non-obese females with optimized neck extension.…”

The 2015 Difficult Airway Society guidelines: what about the anticipated difficult airway? A reply

“…In 2011, the Medicines and Healthcare products Regulatory Agency (MHRA) issued a safety alert following the death of a patient from septicaemia secondary to crossinfection from a poorly decontaminated laryngoscope handle [1]. Subsequently, a number of single-use laryngoscope sets have been manufactured where both handle and blade can be disposed of.…”

Airway assessment/management paradigm – does a spectral or a binary approach fit better? A reply

“…Instead, using a binary pragmatic approach as we suggest, these patients are simply to be classed 'plausibly easy' and any SAD to hand could then be used. Only if it does not work well should it be pragmatically exchanged for another (type or size) [3], or in the rare event of true airway difficulty (despite signs of 'easy') then difficult airway algorithms applied [4,5].…”