Embracing technical improvements in airway management

Abstract

The surgical on-call team approach a female aged in her mid-30s. She has CT-proven appendicitis and has been kept ‘nil by mouth’ overnight. The consultant takes a seat next to the bed and following introductions and a quick re-assessment, they decide she will need to have it removed surgically. They explain the basics of the procedure, and then pause for a moment. ‘Now, we do have this newer approach whereby we make a few keyholes and remove it with the help of a camera and a couple of ports. It leaves a much smaller scar, causes less pain, and can have you home earlier and back to your normal activities sooner than with an open approach [1]. But I'm just more used to doing it the old-fashioned way, so I am not entirely sure I can offer you this. Also, it takes a fair bit of kit and all sorts of faff. So I guess we'll just consent for an open appendicectomy, shall we?’ Claiming that I found the editorial by Lyons and Harte a refreshing read would be disingenuous [2]. In fact, I imagine many clinicians advocating for the adoption of universal videolaryngoscopy (VL) have grown tired of endless conversations, in academic circles and in anaesthetic rooms, about the merits of direct laryngoscopy (DL) over VL. The anecdotes that ‘one time where DL saved the day’ after a poorly executed hyperangulated VL approach had failed. Or blanket regurgitated statements about the bleeding tonsil where ‘VL is useless anyway’, without anyone even attempting it or being able to produce any robust evidence to support the notion. This editorial makes a tenuous stab in trying to dismantle the now overwhelming evidence favouring VL over DL for most technical and patient-oriented outcomes [3]. At this point, I hope that most readers will agree that such a claim is contentious and does not hold much water at the best of times. We may argue that in 9 out of 10 times, securing the airway will be easy, even though our clinical bedside tests to predict difficulty are notoriously flawed [4]. Adopting a ‘marginal gains’ attitude to improving clinical practice, especially for a risk-laden procedure such as asleep tracheal intubation, with the knowledge that each subsequent attempt after the first one will increase the odds of an adverse outcome, we should be using tools with the best efficacy and safety record [5]. However, there is much work to be done to ensure safe and effective training in VL, with a high-quality hyperangulated VL technique being at the forefront of these efforts. Equally, a universal VL clinical milieu allows the intubator to maintain DL skills, using the best tool to teach DL: a Macintosh-style videolaryngoscope. The fictitious and exaggerated patient interaction I wrote at the beginning, which I hope has never actually taken place, is not unlike our attitudes to the tools and approaches we use in the conduct of anaesthesia. If we were to speak to patients with full candour, a similar conversation would have to take place when defending the routine use of DL today. I hope that as a specialty we can follow in the footsteps of, not only the commonly referred to aviation industry and its attitudes to safety, but also our surgical colleagues.