A response to ‘Difficult Airway Society guidelines for management of the unanticipated difficult intubation’, Henderson JJ, Popat MT, Latto IP and Pearce AC, Anaesthesia 2004; 59: 675–94

Firstly, I'd like to thank the author and the editorial board for their wise decision in publishing the Special Article by the Difficult Airway Society. It is an outstanding piece of work. The editorial by Dr W. A. Chambers is, however, very concerning. I feel the editorial has unnecessarily muddied the waters for the following reasons: The DAS authors in their paper do not advocate the use of laminated flow charts while a patient is desaturating, as Dr Chambers suggests. The flow charts in question are beautifully designed and thought out, and replace the existing ASA algorithm, which lacks all of the above qualities. They are a logical and well presented tool to use in teaching, training, simulation and so on. This will in time translate into clinical practice. Having a laminated copy sitting on the drug trolley in every theatre as a morning refresher for trainees, and dare I say consultants, would not hurt either. At no point do the DAS authors say that in the CICV scenario the immediate recourse should be to cricothyrotomy. That's simply not how the algorithms run, so Dr Chambers's comment is misleading. Is cricothyrotomy a core skill? The appropriate question to ask is ‘can we afford it not to be a core skill?’ When the chips are down, what does Dr Chambers suggest we do? Dr Chambers's personal experience in never having to resort to this measure I don't think should be entered into. The ‘I’ve never had to do it so why should we teach it?' approach has no place in print. Lives are still lost and saved on surgical airway access or lack thereof. Should we be encouraging more liberal use of succinylcholine in the hands of the inexperienced as Dr Chambers suggests? A return to the past perhaps? As we know from experience and literature, succinylcholine gives neither reliable good intubating conditions nor reliable rapid recovery. Anaphylaxis issue aside, this is a very dangerous and retroactive suggestion! Again, I wish to congratulate the DAS authors on a superb paper.