Correspondence
Education and research in anesthesia have increasingly focused on the management of difficult airways, leading to the development of new devices that are gradually becoming available and part of routine use across the globe. It is rather interesting to assess whether we have made much progress in using such devices over the past decade.
We read with great interest the letter ‘Should we really consider to lay down the Macintosh laryngoscope?’1, in which Merli G. et al. discuss the present and future roles of video laryngoscopes and the continued value of older instruments, i.e. the Macintosh direct laryngoscope. We agree with the authors that over the past two decades, a large number of airway devices have been introduced into clinical practice.
Data from the early 2000s suggest that, despite the widespread availability of newer airway equipment, traditional techniques (direct laryngoscopy, laryngeal mask airway (LMA), and flexible fiberoptic endoscopy) were the preferred techniques for intubation (Table 1). Ezri et al.2 reported in 2003 that US attending anesthesiologists preferably used flexible fiberoptic endoscopy (75%) for difficult airway management and preferred LMA (81%) in failed intubation/ventilation scenarios. Similarly, in 2004, fiberoptic endoscopy (64%) and some form of blind technique (26%) were used by anesthesiologists in the UK4. In 2005, practitioners in Canada preferred fiberoptic endoscopy (34%) and direct laryngoscopy (48%)5. In most surveys, lack of availability and training with newer equipment was of concern2–5.
Table 1. Outcomes of surveys completed regarding the preference of alternative airway management devices by geographical area and year completed.
| Geographical area of survey | Year | Alternative device outcomes |
|---|---|---|
| Canada3 | 2002 | Fiberoptic (34%) and direct laryngoscopy (48%) |
| USA2 | 2003 | Fiberoptic (75%) for difficult airway management LMA (81%) in failed intubation/ventilation scenarios |
| UK, Oxford Region4 | 2004 | Fiberoptic (64%) and blind technique (26%) |
| Canada6 | 2013 | Video laryngoscope (90%) |
We analyzed the utilization rates of alternative airway devices using data collected between 2008 and 2010 at our institution, the University of Texas Medical School at Houston, Memorial Hermann Hospital – Texas Medical Center (Table 2).
Table 2. Alternative airway device usage rates and first attempt success rates at our institution, Memorial Hermann Hospital – Texas Medical Center at Houston, TX, USA: n, number of responders that prefer the use of a particular device for the majority of cases; usage rate, the percentage of responders that prefer the use of a particular device for the majority of cases; first attempt success rate, number of cases in which successful intubation was achieved in the first attempt.
The most commonly used alternative airway devices were oral fiberoptic intubation (OFOI), (n=318, usage rate=3.69%, first attempt success rate=92.5%), the Glidescope® video laryngoscopy system (Verathon Inc, USA), (n=223, usage rate=2.59%, first attempt success rate=95.5%), the Storz C-MAC® video laryngoscopy system (Karl Storz, Germany), (n=154, usage rate=1.79%, first attempt success rate=94.8%), the Aintree Intubation Catheter (Cook Critical Care, USA), (n=106, usage rate=1.23%, first attempt success rate=96.2%), bougie (n=92, usage rate=1.07%, first attempt success rate=95.7%) and nasal fiberoptic intubation (NFOI), (n=92, usage rate=1.07%, first attempt success rate=85.9%). Among these devices, OFOI and NFOI most likely required multiple intubation attempts, while the other devices had relatively high rates of success on the first intubation attempt.
When comparing our results with those obtained by Ezri et al.2, the most striking difference is the increased use of video laryngoscopes. Ezri et al., reported fiberoptic intubation and the LMA as the most popular in management of the difficult airway; no data was reported on the utilization rates of video laryngoscopes. The results of a similar survey completed by Canadian Anesthesiologists were recently presented at the Society of Airway Management Meeting 2013, where Mehta et al.6 showed that the preferred alternative airway technique in difficult intubation situations was video laryngoscope. In a 2005 survey5 the same authors found that the preferred devices were lighted stylet, bronchoscope, and intubating laryngeal mask airway (Table 1).
There has been a rapid acceptance of video laryngoscopy as an important technique in the management of difficult airway situations. It is our opinion though, that while video laryngoscopy is preferred for ease of use and a faster learning curve, the technique of flexible fiberoptic endoscopy offers invaluable advantages: nasal and oral intubation, double lumen tube or bronchial blocker placement for thoracic surgery, therapeutic bronchoscopy, and it is preferred for awake technique intubation. The device versatility also makes it economical not to mention the greater value of education and training of future anesthesiologists.
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