Postępowanie w przypadkach przewidywalnej trudnej intubacji. Komentarz do artykułu M. Łasińskiej-Kowary i wsp. „Complications after using the Airtraq laryngoscope for a predicted difficult intubation”

Abstract

We read the paper by Łasińska-Kowara and colleagues with great interest [1]. The report presenting the case of a predicted difficult intubation educational. We do believe, however, that the strategy chosen raises many doubts and compels us to think how the described sequence of events during attempted intubations could have been avoided.Based on the history taking and physical examination, possible difficulties in endotracheal intubation for a scheduled surgical procedure in the prone position were rightly anticipated. The authors decided to attempt an intubation using the Airtraq laryngoscope (plan A) under local anaesthesia and sedation and fibreoptic intubation under sedation (emergency plan B).The conclusions presented in the 4 th National Audit Project (NAP 4) explicitly indicate that many complications associated with securing the airway in patients with predicted difficult intubations were caused by not implementing of awake fibreoptic intubation technique [2]. According to the recommendations of the American Society of Anaesthesiologists (ASA) and Australian and New Zealand College of Anaesthetists (ANZCA) [3], fibreoptic intubation should be the first-choice method for predictable difficult intubation.Despite increasingly available video laryngoscopes, according to the Frerk and ANZCA guidelines, there is no evidence that standard laryngoscopes should be replaced by their non-standard equivalents (e.g. Airtraq) in difficult intubations. It is puzzling that the authors decided to use the laryngoscope knowing that the inter-canine distance was markedly limited (2.2 cm; normal > 3.5 cm) and difficulties in laryngoscopy were extremely likely to occur.In anticipated difficult intubations and when the use of video-or fibrescopic devices is intended, the presence of saliva can significantly hinder visualisation [5,6]. The authors do not mention the use of atropine or glycopyrrolate during preparation for anaesthesia, which are administered to provide "a dry" operating field.Many articles and textbooks emphasize that successful intubations mostly depend on efficient local anaesthesia rather than deep sedation [5,6]. Patients under deep sedation or even ligth general anaesthesia after premedication with midazolam, 15 mg, followed by intravenous fentanyl, midazolam and propofol are at risk of suboptimal airway maintance. Good doctor-patient communication is essential during any procedure under local anaesthesia. Therefore, in such cases the commonly used drug is remifentanil, a controllable opioid, in intravenous infusions.The authors` statement that "after preoxygenation, we achieved an appropriate level of sedation" might suggest that during the intubation attempts, passive oxygenation was not attempted. The majority of authors emphasize the importance of continuous oxygen delivery during fibreoptic intubation via the oxygen nasal cannula or a nasal suction catheter [3,[5][6][7][8].The dramatic events (bleeding, desaturation) described by the authors in details made direct and fiberoptic laryngoscopy impossible...