Airway Management

To the Editor The editorial by Hung and Murphy,1 although interesting, contains potentially misleading statements. Some have opined that careful evaluation of the airway as part of a preplanned strategy may lead to improved outcome.2 However, it is potentially dangerous to suggest that the choice of the technique and hence the choice of the equipment is or should be influenced primarily by different circumstances. Advocating such an approach would result in multiple strategies using many different and, at times, unfamiliar airway devices. Only a few studies have focused on effective airway management and, in these, outcome was investigated under the prevailing clinical conditions.3–5 A common characteristic of each of these studies was a limitation of techniques and devices and that deviation from the predefined algorithm was recorded infrequently. A key factor regarding safety recorded by highly reliable organizations such as aviation is a standardized process.6 However, the “recommendations” of Hung and Murphy that airway management is primarily “context sensitive” would guide us in the wrong direction. There are only a few situations wherein we might deviate from our difficult airway guidelines. For example, it is very unlikely that you can perform an awake intubation in an uncooperative patient. Importantly, such situations should be managed by the most experienced physicians. However, if deviation from, rather than adherence to, the guidelines is current practice, the guidelines should be modified accordingly. A second point is the missing commitment to fiberoptic intubation (“unwritten truth”). If the authors mean that there are no prospective randomized studies showing the effectiveness of fiberoptic intubation, they are correct. Unfortunately, there are no prospective randomized studies demonstrating the effectiveness (not efficacy) of most techniques used in daily practice. However, it is generally agreed among airway management practitioners and recommended by many anesthesia societies that fiberoptic intubation should be used for management of the anticipated difficult airway.7 So, questioning this technique is probably potentially misleading for the average anesthesiologist in practice. Regarding airway management, the message should be: Standardization, simplicity, and daily practice are the keys to success.