Tracheal tube introducers: choose and use with care

Abstract

Tracheal tube introducers are accepted aids in managing difficult intubation in the UK. There are many single-use introducers on the market. Choosing an appropriate model can be difficult. In our opinion, an inappropriate introducer is one that has not been evaluated or has been found to have a low success rate and a high potential for airway trauma. The Eschmann (Smiths Medical International, Hythe, UK) multiple-use and Frova (Cook UK Ltd, Letchworth, UK) single-use introducers are the standard devices against which others are usually compared (gold standard). Our 2005 national survey [1] found that serious airway trauma was associated with the use of tracheal tube introducers. We conducted a follow-up survey of introducer availability and associated airway trauma in 2009. A postal questionnaire was sent to the college tutors of all 275 anaesthetic departments in the UK. Information was sought on the introducer type availability and on airway trauma associated with the use of tracheal tube introducers during the preceding 12 months. Replies were received from 175 of the 275 college tutors giving a 64% response rate. Eschmann and Frova (our gold standard) were the sole introducers available in 68 (39%) departments. However, 78 (45%) departments had both gold standard and inappropriate devices available and 29 (17%) departments had only inappropriate devices available for use. Twenty-four of these 29 departments had only Portex (Smiths Medical International) or ProBreathe (Pro-Act Medical Ltd, Northampton, UK) introducers available, which we found to have unacceptably low success rates and high potential for airway trauma [2]. Six cases of airway bleeding were associated with the Frova introducer, two pneumothoraces with the Portex introducer and one death following mediastinitis with the Eschmann introducer (the airway trauma in this case might have been caused either by the tracheal tube or the introducer – personal correspondence). Ninety-seven (51%) departments in our 2005 survey had inappropriate introducers available, compared to 107 (61%) departments in this survey. We recommend caution when choosing these devices. Ready availability of critically appraised evidence will aid these choices. Establishment of an ‘airway devices evaluation group’ [3] is a step in the right direction. We also recommended the establishment of a free website containing expert advice on equipment purchasing [4]. Clinicians desperately need easy access to such evidence-based advice, since buying an inappropriate device and thus imposing its use, will disadvantage their colleagues and have serious consequences for some patients. The material in this letter has been presented as a poster presentation at the Annual Congress of the AAGBI, September 2009. No external funding and no competing interests declared.