Affiliations: Department of Critical Care Medicine,
Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA,
UMass Memorial Medical Center, Worcester, MA
Correspondence to: Ali Al-Khafaji, MD, MPH, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall 613, Pittsburgh, PA 15213; e-mail: firstname.lastname@example.org
We read with great interest the article by Walz et al1 published in the February issue of CHEST. We would like to congratulate them on their excellent and comprehensive review on this important subject, and we would like to emphasize two important issues.
First, the authors did not expand on the beneficial use of elastic gum bougie, which is as an excellent surrogate tool that can be used in difficult airway specially in patients with Cormack and Lehane grade III and IV views.2 Intensivists should be familiar with the bougie before they can comfortably use it in a real “difficult” airway situation. During routine intubation, one could make grade I and II views more difficult by lifting the laryngoscope with less force, allowing the epiglottis to cover the vocal cords. This will allow the blind placement of the bougie and subsequently advancing the endotracheal tube over it.
Second, the use of muscle relaxants should not be discouraged because they provide an advantage in “improving” the view during intubation. The “phobia” of using muscle relaxants that exists among intensivists with no training in anesthesia can potentially lead to difficulty and/or possible complication such as laryngeal injury/spasm while advancing the endotracheal tube through moving cords. If the intensivist elects not to use muscle relaxants during intubation, the combination of propofol and remifentanil might be a suitable alternative.3–4 In dealing with critically ill patients, we do not have the luxury of waking the patient up if intubation is not possible. Therefore, optimizing intubating condition is essential. Instead of discouraging the use of muscle relaxants, the nonanesthesia trainee should be encouraged to do electives in anesthesia in order to take the fear factor out and to make them more comfortable in using muscle relaxants. This is routinely done in the United Kingdom.
The authors have no conflicts of interest to disclose.
We appreciate the letter from Al-Kafajhi et al and their interest in our recent review in CHEST (February 2007)1of airway management in critical illness. We agree that the gum-elastic bougie (Eschmann stylet) can be a valuable tool in the armamentarium of the intensivist during emergency airway management. Anesthesia electives for all physician staff involved in ICU care would be desirable; however, we are concerned about the proposed method of familiarizing the intensivist with the use of the gum-elastic bougie. Worsening the view during elective intubation to create a “pseudo-difficult” laryngoscopy may not be in the patient’s best interest and, to our knowledge, does not represent a validated teaching tool. The majority of intensivists without a background in anesthesia will not be familiar with the device, which can cause complications2–3; it is not part of the American Society of Anesthesiologists difficult airway algorithm.
As the authors pointed out in their letter, there are suitable alternatives to the use of muscle relaxants for achieving acceptable intubation conditions while maintaining spontaneous ventilation by the patient. Although our caution regarding the use of muscle relaxants during intubation might be interpreted as a “phobia,” we prefer to think of it as “prudent.” Yes, we cannot wake the patient if attempts at intubation fail, but at least we still have a patient who is breathing spontaneously. Last, as we mentioned in our review, the risk of developing hyperkalemia following the administration of succinylcholine is unpredictable in the ICU patient. Large doses of nondepolarizing muscle relaxants can achieve intubation conditions equivalent to those using succinylcholine4–5 but cannot be reversed if intubation fails. Perhaps with the advent of sugammadex (an IV steroidal binding agent),6 a rapid reversal of a large dose of a nondepolarizing agent will be possible in the setting of failed intubation during emergency airway management, thus making the use of this class of drug safer in the ICU.
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