Abandoning awake fibreoptic bronchoscopy - a reply.

Abstract

We were pleased, but not entirely surprised, at the responses generated by our recent editorial 1. We are sorry if we gave Schechtman et al. the impression that, based on the results of the study by Lee et al. 2, we were suddenly convinced that fibreoptic intubation was no longer a viable option in airway management. Rather, we decided to use the study as a board from which to dive into the swimming pool of debate, which is why we posed the title as a question rather than a statement. Contrary to Morris’ assertion that ‘it is an easy technique and most people have the skills for success, but it is the confidence that they lack’ we believe that awake fibreoptic intubation (AFOI) is not an easy technique to master and most do not have the requisite skills for success, which is precisely why they lack the confidence. We agree with both Ward and Bell and Beatty that the opportunities for training and retaining competence in awake fibreoptic intubation are limited in the UK and this is due to a combination of factors that include: a reduction in training hours; the increasingly widespread adoption of alternative devices such as videolaryngoscopes; employment of oxygenation techniques such as transnasal humidified rapid-insufflation ventilator exchange (THRIVE) 3 that improve the safety of patients during intubation attempts; and the increased use of sugammadex to quickly reverse the effects of neuromuscular blockade when rocuronium has been administered. Bell and Beatty point out that 27 fibreoptic intubations are thought to be required to achieve competence, yet only 17 were performed in their hospital the previous year. Even in our unit where approximately 17 AFOIs are performed each month, there are still not enough cases for all our anaesthetists to gain or retain competence in this procedure. The overall lack of suitable ‘natural’ human difficult airway cases can lead to ethical issues; whilst asleep oral fibreoptic intubation performed in a patient whose trachea would otherwise be intubated orally in a standard fashion for, say, a laparotomy, may be acceptable, an awake nasal fibreoptic intubation performed in an elective patient with a simulated difficult airway (by the placement of a hard cervical collar, for example) who is scheduled for an elective hernia repair might well be viewed as unethical. This is where we feel sure many anaesthetists differ in their views; the enthusiasts would argue that this sort of training is justified whilst others would be aghast at the idea. Simulation is useful, but not the complete answer, it largely addresses fibrescope handling skills. Topicalisation of the airway, oxygenation techniques, positioning of the patient and skillful sedation techniques are an important part of an AFOI and also need to be learnt. Heidegger states that we wish to discredit fibreoptic intubation. We don't, we merely wanted to generate discussion. He criticises the methodology of Lee et al. and we will leave the authors themselves to comment on the details of their study. He also argues that, because all national airway societies recommend fibreoptic intubation as a ‘gold standard’ for managing the difficult airway, that anaesthetists have a professional duty to master the technique and maintain expertise. We agree with Dalton and Rodney that the term ‘gold standard’ is unhelpful because how can all anaesthetists achieve this when there are simply not enough opportunities? We still believe that fibreoptic intubation has its place in certain situations, such as in patients with abnormal anatomy and/or have predictors of difficult bag/valve/mask ventilation where safety is paramount, but that it should no longer be considered the ‘gold standard’ for difficult airway management because not all difficult airways are the same. Like all specialised techniques, a skilled specialist should use it in an appropriate situation.