Tracheal intubation without the use of neuromuscular blocking drugs. Reply to Br J Anaesth 2018; 121: e9–10

Abstract

Editor—I thank Boselli1Boselli E. Intubation without NMBA: first optimise opioid dose. Comment on Br J Anaesth 2018; 120: 1150–3.Br J Anaesth. 2018; 122: e9-e10Google Scholar for his comments on my editorial,2Hunter J.M. Optimising conditions for tracheal intubation: should neuromuscular blocking agents always be used?.Br J Anaesth. 2018; 120: 1150-1153Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar written in response to Lundstrom and colleagues' meta-analysis3Lundstrom L.H. Duez C.H.V. Norskov A.K. et al.Avoidance of use of neuromuscular blocking agent for improving conditions during tracheal intubation: a Cochrane systematic review.Br J Anaesth. 2018; 120: 1381-1393Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar reporting the benefits of using neuromuscular blocking agents (NMBAs) to aid tracheal intubation. My major concern with Boselli's argument is that the research he reports is limited to ASA physical status 1–2 patients receiving high doses of remifentanil (4 μg kg−1). A decrease in mean arterial blood pressure of 20% induced by such doses would be considered unacceptable in sicker patients as has recently been discussed in this journal.4Wesselink E.M. Kappen T.H. Tom H.M. Slooter A.J.C. van Klei W.A. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review.Br J Anaesth. 2018; 121: 706-721Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar As Boselli admits,1Boselli E. Intubation without NMBA: first optimise opioid dose. Comment on Br J Anaesth 2018; 120: 1150–3.Br J Anaesth. 2018; 122: e9-e10Google Scholar anaesthetists rarely optimise their anaesthetic protocol, and more research is still necessary to define the optimal doses of opioid analgesic in different groups of patients using this technique. Importantly, studies should only consider protocols that define efficacy in at least 95% of patients. Considering efficacy in 50% of patients has no clinical relevance to intubating conditions. In addition, the approach Boselli recommends of optimising the anaesthetic technique to provide ideal conditions for tracheal intubation without use of NMBAs does not allow for unexpected difficulty. I do accept, however, that such techniques need to be refined further for use in patients where administration of NMBAs is contraindicated.5Hunter J.M. Should NMBAs always be used for tracheal intubation?.Br J Anaesth. 2018; 122: e7Google Scholar J.M.H. was Editor-in-Chief of the British Journal of Anaesthesia (BJA) from 1997 to 2005 and Chair of the BJA Board from 2006 to 2012. Intubation without NMBA: first optimise opioid dose. Comment on Br J Anaesth 2018; 120: 1150–3British Journal of AnaesthesiaVol. 122Issue 1PreviewEditor—I read with interest the editorial by Hunter1 on the use of neuromuscular blocking agents (NMBA) for tracheal intubation, and do not agree with the author's conclusion that ‘Studies into intubating conditions can no longer be considered boring but, in my view, there is no need for the question of whether NMBAs should be used for tracheal intubation to be investigated further. Unless there is a specific contraindication to their use, they should be’.1 The conclusions from the related meta-analysis by Lundstrøm and colleagues2 are more moderate, stating that ‘the use of NMBA may create better conditions for tracheal intubation in clinical practice than avoidance of NMBA’. Full-Text PDF Open Archive