Correspondence  |   July 2017
Assessing Success of Rescue Intubation Techniques after Failed Direct Laryngoscopy
Author Notes
  • Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (F.-S.X.).
  • (Accepted for publication April 9, 2017.)
    (Accepted for publication April 9, 2017.)×
Article Information
Correspondence   |   July 2017
Assessing Success of Rescue Intubation Techniques after Failed Direct Laryngoscopy
Anesthesiology 7 2017, Vol.127, 198-200. doi:10.1097/ALN.0000000000001689
Anesthesiology 7 2017, Vol.127, 198-200. doi:10.1097/ALN.0000000000001689
In a multicentered, observational study comparing the success rate of commonly used rescue intubation techniques after a failed direct laryngoscopy, Aziz et al.1  showed that video laryngoscopy was associated with a higher success rate of rescue intubation and was more commonly used than other tools, including a fiberoptic bronchoscope, a supraglottic airway device, an optical stylet, and a lighted stylet. In addition to the limitations described in the discussion, however, there are several questions in this study that must be clarified.
First, the majority of rescue intubations (1,023 of 1,511 cases, 68%) were defined after one failed direct laryngoscopy attempt. This practice is not in agreement with the definition of difficult or failed laryngoscopy in the current practice guidelines for difficult airway management by the American Society of Anesthesiologists.2  Because the authors did not provide the detailed causes of failed direct laryngoscopy, it was unclear why the anesthetists abandoned direct laryngoscopy after the first attempt. In fact, difficulty in performing laryngoscopy depends on the anesthetists’ level of skill, the patient’s features, and procedure circumstances. In this study, the authors did not specify whether an optimal-best laryngoscopy attempt was executed when a failed direct laryngoscopy was defined. The components of an optimal-best laryngoscopy attempt include a reasonably experienced (at least 3 full recent years) anesthetist, use of an optimal sniffing position, change of length or type of blade one time, and use of external laryngeal manipulation.3  Only when an optimal-best laryngoscopy attempt is performed may difficult or failed laryngoscopy be readily obvious to an experienced anesthetist on the first attempt and thus is independent of both number of laryngoscopy attempts and time. According to the data provided by the authors, we cannot determine whether a definitively failed direct laryngoscopy occurs in each patient receiving rescue intubation.
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