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Rebuttal From Dr DoerschugRebuttal From Dr Doerschug FREE TO VIEW

Kevin C. Doerschug, MD, FCCP
Author and Funding Information

From the Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine.

Correspondence to: Kevin C. Doerschug, MD, FCCP, C33 General Hospital, Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242; e-mail: kevin-doerschug@uiowa.edu


Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Doerschug is the program co-chair of the American College of Chest Physicians Airway Management Simulation Education Program.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(6):1378-1379. doi:10.1378/chest.12-2197
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As I read Dr Walz’s1 submission, I am aware of how much we agree. I concur that

  • 1. Complications of ICU intubations are largely due to factors of critical illness;

  • 2. Difficulties are frequently unexpected; that is, every airway should be approached as potentially difficult; and

  • 3. Whoever performs ICU intubations should be skilled at various techniques.

Despite this agreement and similar data, our opinions diverge.

Dr Walz notes a possible discrepancy in the number of intubation attempts between specialties with good reason. Multiple attempts are both (1) markers of difficulty and (2) direct causes of laryngeal edema that impair subsequent rescue and can hasten death. Accordingly, the relatively high rate of complications of direct laryngoscopy (DL) seen in Mayo and colleagues,2 including three or more attempts in 20% of patients, provokes some angst. Yet, the goal of intubation is not to limit DL but to preserve cardiopulmonary homeostasis. Severe hypoxemia occurred in 14% of their cohort and severe hypotension in 6%. Conversely, Simpson and colleagues3 reported very low rates of DL complications but severe hypoxemia in 22% and severe hypotension in 10% of patients managed by anesthesiologists. In this regard, the systematic, team-oriented approach of Mayo’s pulmonary group successfully limited important complications of ICU intubations.

Recognizing the limits of DL and moving to alternative techniques before physiologic compromise are critical steps in ICU airway management. Videolaryngoscopes4 and, perhaps more importantly, intubating extraglottic airways demonstrate high success rates in emergency intubations and in the hands of nonanesthesiologists.5,6 I concur that these devices should not justify otherwise underqualified operators, yet one cannot deny their contributions to patient safety. Intensivists must ensure that these devices are available and incorporated into a systematic approach to ICU intubations. Like anesthesiologists, pulmonologists must advance their skills as new technologies are developed.

The main argument against pulmonary-intensivists performing ICU intubations is based on their relative inexperience. The data do not demonstrate that a change to an anesthesiologist improves outcomes. Rather, pulmonologists skilled in multiple techniques and teamwork can limit severe complications. Thus, the approach most likely to improve patient outcomes is for pulmonary-intensivists to perform more intubations, not fewer. Intensivists who actively intubate are in the best position to build the optimum environment for ICU intubations. Clearly, there is work to be done. This notion echoes in the voice of a man (a pilot trained in crew resource management) who lost his wife to failed airway management in the operating room: “I did not want them to lose their jobs. I wanted them to return to work and improve things.”7

At times, it may be prudent for an anesthesiologist to perform the second operator role. This should be a collegial, not adversarial, relationship. One anesthesiologist’s view of EDs seems true for the ICU: “It would seem that a rift has developed between [our specialties] which has pitted each against the other….This dysfunctional competition has undermined collaboration…and patient care.”8

Pulmonologists—and our patients—will benefit from a systematic approach and collaboration with anesthesiologists. Together, rather than separately, we are more likely to address the complexities of ICU airway management.

References

Walz JM. Point: should an anesthesiologist be the specialist of choice in managing the difficult airway in the ICU? Yes. Chest. 2012;142(6):1372-1374. [CrossRef] [PubMed]
 
Mayo PH, Hegde A, Eisen LA, Kory P, Doelken P. A program to improve the quality of emergency endotracheal intubation. J Intensive Care Med. 2011;26(1):50-56. [CrossRef] [PubMed]
 
Simpson GD, Ross MJ, McKeown DW, Ray DC. Tracheal intubation in the critically ill: a multi-centre national study of practice and complications. Br J Anaesth. 2012;108(5):792-799. [CrossRef] [PubMed]
 
Noppens RR, Geimer S, Eisel N, David M, Piepho T. Endotracheal intubation using the C-MAC® video laryngoscope or the Macintosh laryngoscope: a prospective, comparative study in the ICU. Crit Care. 2012;16(3):R103. [CrossRef] [PubMed]
 
Mosier JM, Stolz U, Chiu S, Sakles JC. Difficult airway management in the emergency department: GlideScope videolaryngoscopy compared to direct laryngoscopy. J Emerg Med. 2012;42(6):629-634. [CrossRef] [PubMed]
 
Timmermann A, Russo SG, Crozier TA, et al. Novices ventilate and intubate quicker and safer via intubating laryngeal mask than by conventional bag-mask ventilation and laryngoscopy. Anesthesiology. 2007;107(4):570-576. [CrossRef] [PubMed]
 
Bromiley M. Just a routine operation. YouTube website.http://www.youtube.com/watch?v=JzlvgtPIof4, Accessed August 29, 2012.
 
Mort TC. Anesthesia practice in the emergency department: overview, with a focus on airway management. Curr Opin Anaesthesiol. 2007;20(4):373-378. [CrossRef] [PubMed]
 

Figures

Tables

References

Walz JM. Point: should an anesthesiologist be the specialist of choice in managing the difficult airway in the ICU? Yes. Chest. 2012;142(6):1372-1374. [CrossRef] [PubMed]
 
Mayo PH, Hegde A, Eisen LA, Kory P, Doelken P. A program to improve the quality of emergency endotracheal intubation. J Intensive Care Med. 2011;26(1):50-56. [CrossRef] [PubMed]
 
Simpson GD, Ross MJ, McKeown DW, Ray DC. Tracheal intubation in the critically ill: a multi-centre national study of practice and complications. Br J Anaesth. 2012;108(5):792-799. [CrossRef] [PubMed]
 
Noppens RR, Geimer S, Eisel N, David M, Piepho T. Endotracheal intubation using the C-MAC® video laryngoscope or the Macintosh laryngoscope: a prospective, comparative study in the ICU. Crit Care. 2012;16(3):R103. [CrossRef] [PubMed]
 
Mosier JM, Stolz U, Chiu S, Sakles JC. Difficult airway management in the emergency department: GlideScope videolaryngoscopy compared to direct laryngoscopy. J Emerg Med. 2012;42(6):629-634. [CrossRef] [PubMed]
 
Timmermann A, Russo SG, Crozier TA, et al. Novices ventilate and intubate quicker and safer via intubating laryngeal mask than by conventional bag-mask ventilation and laryngoscopy. Anesthesiology. 2007;107(4):570-576. [CrossRef] [PubMed]
 
Bromiley M. Just a routine operation. YouTube website.http://www.youtube.com/watch?v=JzlvgtPIof4, Accessed August 29, 2012.
 
Mort TC. Anesthesia practice in the emergency department: overview, with a focus on airway management. Curr Opin Anaesthesiol. 2007;20(4):373-378. [CrossRef] [PubMed]
 
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