Reply

Abstract

EDITOR: Dr Kotsev's comments seem to stem from an archaic attitude towards airway management and a failure to grasp the importance of bougie-guided insertion of the ProSeal laryngeal mask airway for airway rescue [1,2]. We will address each of his points in turn. First, this patient was reviewed both by a second anaesthetist and a clinical psychologist who found that he had a rational fear of awake intubation: his brother had undergone a rather gruesome awake intubation for an elective cholecystectomy (on the basis of having buck teeth and a beard) which left him with a vocal cord injury. Second, spontaneous breathing was not lost after induction. We took over the patient's ventilation to allow better gas exchange and to deepen anaesthesia. Having established successful ventilation, we felt it was safe to administer a muscle relaxant. It is debatable as to whether suxamethonium would have been a better choice than atracurium. Third, the principle that ‘the natural airway is better maintained when the patient remains breathing spontaneously’ makes little sense and is almost certainly wrong. The natural airway is usually lost once the patient is anaesthetised and gas exchange is usually worse with spontaneous rather than positive pressure ventilation. Other than providing information about depth of anaesthesia and perhaps reducing the frequency of gastric insufflation and barotrauma, spontaneous breathing under anaesthesia is neither natural nor beneficial. Fourth, the concept that inhalational anaesthesia is best if airway problems are anticipated is entrenched in anaesthesia teaching, yet few clinicians adhere to it and it remains (and probably always will be) unproven. The primary benefit of inhalational induction is that if problems arise they occur slowly and can easily be reversed – but is this true? More importantly, can these problems be reversed more rapidly than after an intravenous induction with modern short acting agents? There is no answer. Certainly, most of us have experienced horrendous gas inductions in adults. Fifth, it took less than 20 s to work through the section of the algorithm which relates to guided insertion techniques, and a further 10 s to remove the ProSeal laryngeal mask airway and railroad the tracheal tube into position. Thus we wasted no time in securing the patients airway. The minimal SPO2 was 94%. Our algorithm is not particularly complex: it certainly has fewer steps than the American Society of Anesthesiologists difficult airway algorithm. Sixth, we do not consider that there are compelling reasons to perform awake tracheal intubation in a patient with a history of difficult tracheal intubation if other forms of airway management have proved to be easy. In this case, face mask ventilation was known to be easy (admittedly it required a Guedel airway) and there were no signs that laryngeal mask airway insertion/function would be difficult. Certainly, if both face mask ventilation and laryngeal mask airway insertion are predicted to be easy, it is difficult to justify awake tracheal intubation, especially against a patient's wishes. Finally, all anaesthesiologists should familiarise themselves with the bougie-guided technique for insertion of the ProSeal laryngeal mask airway. It is a powerful yet simple new concept in airway management: using a tube that is easily accessible (the oesophagus) to secure access to a tube that is not easily accessible (the trachea). The combination of the best extraglottic device with this new technique for placement results in remarkably high insertion success rates. In our experience of over 15 000 uses, it has a failure rate of 0.5% falling to 0.1% after the application of the algorithm. We recently found that even personnel with no experience of airway management have exceptionally high success rates (100 out of 100 patients) following brief manikin-only training [3]. In our view, it is one of the most successful airway management techniques in anaesthesia practice today and our algorithm further increases its success.