Journal of ISSN: 2373-6437JACCOA

Anesthesia & Critical Care: Open Access
Editorial
Volume 3 Issue 5 - 2015
Searching for the Perfect Airway Device, too Many Options So Little Time
Juan Carlos Flores-Carrillo*
Anesthesia and Critical Care Medicine, Mexico
Received:December 13, 2015 | Published: December 15, 2015
*Corresponding author: Juan Carlos Flores-Carrillo, Anesthesia & Critical Care Medicine, Hospital Angeles Tijuana, Mexico, Email:
Citation: Flores-Carrillo JC (2015) Searching for the Perfect Airway Device, too Many Options So Little Time. J Anesth Crit Care Open Access 3(5): 00113. DOI: 10.15406/jaccoa.2015.03.00113

Editorial

Securing the human airway thru an invasive method such as an endotracheal tube has been long considered as the standard of care in people undergoing general anesthesia in an elective or urgent surgery. Garcia a singing teacher that developed anatomical and physiological knowledge during his years served in the French military hospitals, was among the first to visualize the glottis in humans in the late 1854 a moment in medical history that combined the arts and science [1]. Since that moment the visualization of the vocal cords has brought many challenges initially thru indirect methods such as dentistry mirrors and reflective light. In 1879 Macewen a surgeon from Glasgow inserted a tube down to the trachea of a patient with glottis edema allowing breathing and consequently saving his life [2]. This particular method was initially thought to be a feasible idea to the commonly tracheostomy and later became a common procedure in surgery. With the development of the autoscope in Germany, Kirsten published “The Technique of Insertion of Endotracheal insufflation tubes”in 1913 [3].              

Anesthesiologist used to intubate most of the patients with or without difficult airway in the operating rooms and as time passed this translated to people suffering from different conditions that represented an imminent failure to oxygenate properly, most of the times tracheal intubation and mechanical ventilation needed to be started. A difficult airway represents a complex interaction between patient factors, the clinical setting and provider skills [4]. These difficult cases can quickly become emergencies with life-threatening complications or even death. Although rare the difficult intubation setting presents in the operating rooms presents in 1.15 to 3.8% increasing to a disturbing range of 9 to 12% in the emergency setting outside the OR [5]. As airway management has evolved and other specialists such as intensive care or emergency physicians acquired the responsibility of securing and establishing a patent airway the risk of doing so in an unstable setting increases the complication rate up to 28% with a mortality of 3% associated with complications such as esophageal intubation, hypoxia, bradycardia and cardiac arrest [6,7]. During training a specialist should undergo at least 57 intubating procedures with a conventional laryngoscope to achieve a 90% success rate [8]. Video assisted intubation was not a popular option at the beginning because of high cost and unpractical rigid designs. Videolaringoscopes utilizes indirect laryngoscopy via its camera improving glottic visualization, usually requiring less force to the base of the tongue and soft tissue [9]. The first popular videolaryngoscope introduced in 2001 to clinical practice was the Glidecope Laryngoscope, Verathon. Equipped with a video screen, anti fog mechanism and a 60-degree angle that improved the glottic exposure even in trauma setting [10]. Over the last 10 years several products have been introduced to clinical practice from various manufactures such as McGrath series 5 (Aircraft Medical), the C-MAC (Storz) and Airtraq (Teleflex). Currently various options of videolaryngoscopes are available with similar or more complex characteristics such as channeled laryngoscopes with a tube slot making an easier delivery to the glottis. Although current video laryngoscope provides an excellent visualization the challenge actually is direct the endotracheal tube thru the vocal cords, requiring practice with manikin ideally before experimenting on a patient or using the device in an emergency setting.

These current and new devices may seem appealing to both the novice specialist and the experienced one. There is a modern concern in teaching hospitals “Do we let the inexperienced trainees start with the videolaryngoscope or wait until they complete practicing the conventional strategy?”. Nouruzi-Sedeh compared the success rate in intubation among novice operators using a video laryngoscope versus the conventional direct laryngoscope with a result of 93% VL success rate compared with 51% for DL [11]. In our past issue a controlled clinical trial by experienced anesthesiologist compared the use of Airtraq and True view EVO2 with Macintosh laryngoscope for endotracheal intubation in which results also favor the use of video laryngoscope (Airtraq) in first attempt success rate withless time to intubate [12], this raises further questions upon what will be the perfect tool for our trade. It may be impossible to compare all of the current airway devices available on today’s market with actual patients or specifically in difficult airway settings. What is a reality is the implementation of Video laryngoscopes in the management of difficult airway suggesting in some cases as the first or second choice in laryngoscopy with the intention of limiting the multiple attempts for intubation [13,14].

What is the perfect airway device? It will be impossible to have all of them in our armamentarium especially in rural hospitals, developing countries, teaching hospitals or private practice. Even less likely to obtain the recommend experience with various devices, the fact is that more people are undergoing emergent or elective surgeries with older, heavier patients and more comorbidities making them a real challenge in modern airway management. Will video laryngoscopy be the standard of care? Our patients will benefit from a well-taken decision considering what tool is the best option for securing the airway and what is the best device in which we have more experience.

References

  1. Radomski T (2005) “Manuel Garcia”: A Bicentenary reflection. Australian Voice 11: 25-41.
  2. Macmillan M (2010) William Macewen [1848-1924]. J Neurol 257: 858-859.
  3. Burkle CM, Zepeda FA, Bacon DR (2004) A Historical Perspective on Use of the Laryngoscope as a Tool in Anesthesiology. Anesthesiology 100(4): 1003-1006.
  4. Apfelbaum JL, Hagberg CA, Caplan RA, Casey DB, Richard TC, et al. (2013) Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologist Task Force on Management of the Difficult Airway. Anesthesiology 118: 251-270.
  5. Mark LJ, Herzer KR, Cover R, Pandian V, Bhatti NI, et al. (2015) Difficult Airway Response Team: A Novel Quality Improvement Program for Managing Hospital-Wide Airway Emergencies. Anesth Analg 121(1): 127-139.
  6. Niven AS (2013) Techniques for the difficult airway. Curr Opin Crit Care 19(1): 1-15.
  7. Mort TC (2004) Emergency Tracheal Intubation: Complications associated with repeated laryngoscope attempts. Anesth Analg 99(2): 607-613.
  8. Mulcaster JT, Mills J, Orlando H, MacQuarrie K, Law JA, et al. (2003) Laryngoscopic Intubation: Learning and Performance. Anesthesiology 98(1): 23-27.
  9. Cooper RM (2005) The Glide Scope video laryngoscope. Anaesthesia 60(10): 1042.
  10. Zaouter C, Calderon J, Hemmerling TM (2015) Video laryngoscopy as a new standard of care. Br J Anaesth 114(2): 181-183.
  11. Nouruzi-Sedeh P, Schuman M, Groeben H (2009) Laryngoscopy via Macintosh blade versus GlideScope: Success rate and time for endotracheal intubation in untrained medical personnel. Anesthesiology 110(1): 32-37.
  12. Dwivedi Y, Srivastava U, Saxena A, Amrita G, Tapas KS, et al. (2015) Comparasion of Airtraq and Truview EVO2 with Macintosh Laryngoscope for Endotracheal Intubation by Experienced Anaesthesiologist: A Controlled Clinical Trial. J Anesth Crit Care Open Access 3: 1-6.
  13. Frek C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, et al. (2015) Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesthesia 115(6): 827-848.
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