Experience in awake fibreoptic intubation: a reply

We thank Drs. Chong and Oti for their comments on our recent article 1. We agree with the stance that training in awake tracheal intubation (ATI) is lacking, hence it would not be the first choice for many anaesthetists when managing a difficult airway. However, at our institution we encourage the use of ATI for the management of difficult airways and actively promote training in this skill for patients with an indication. We perform an average of over 300 ATIs a year 1, although this number is ever-rising, meaning that trainees have opportunities to gain valuable experience. Although we appreciate that not all hospitals are tertiary head and neck cancers like ours and therefore may not have this specific patient group, we believe that regular training on the key facets of ATI is possible outside of this context, including oxygenation, topicalisation, appropriate sedation and finally ‘scope handling’. This latter skill may readily be practiced on simulators, manikins and then on asleep patients, be it with flexible bronchoscopy (FB) or videolaryngoscopy (VL). We concur that asleep airway management strategies involving VL and high-flow nasal oxygenation have provided alternatives to difficult airway management, but we believe that these should complement rather than replace ATI. Awake VL is certainly a valid and useful tool, and the techniques of oxygenation, local anaesthetic topicalisation and conscious sedation are vital transferable skills necessary for both awake VL and FB. Hence, training in awake VL will lend itself well to awake FB training. Additionally, there have been calls for awake VL to become a core anaesthetic skill 2 as a recent meta-analysis demonstrated a similar success rate and safety profile compared with FB 3, and we support the notion that more of these should be incorporated into training. Obtaining and maintaining competence in the procedural skill of awake VL is readily achievable, as the technique is more similar to the asleep approach than FB and therefore more readily practiced. It is pertinent to remember that a myriad of videolaryngoscopes exist, and proficiency in one type does not guarantee proficiency in another 4. Furthermore, VL will still fall short compared with FB in cases with limited mouth opening, hence practice in the latter should still be encouraged. The 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society concluded that every anaesthetic department should have the capability to provide ATI services and more generalised uptake is needed 5. By achieving adequate oxygenation, topicalisation and conscious sedation, ATI (either with FB or VL) can be easier and safer than many may assume. With reductions in training times and the new junior doctor contract, the onus falls more heavily upon individuals to take charge of their own training. We argue that reduced training hours are not to blame for a reduction in ATI training, rather, that the technique seems to have fallen out of favour with many anaesthetists due to lack of regular practice. We agree that active participation in airway courses is imperative and forward thinking with regard to training and undertaking advanced fellowships can help improve and maintain skills in advanced airway management. We would also encourage visits or attachments to centres where large numbers of advanced airway techniques are practiced. Finally, we look forward to the upcoming DAS guidelines on ATI that are hoped to support training and practice in this area.