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doi: 10.1097/ALN.0b013e31827bd239

Flexible Bronchoscopy Still the Definitive Standard for Airway Management

Levine, Adam I. M.D.*; Leibowitz, Andrew B. M.D.

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To the Editor:

We read with great interest, but equal concern, the recent article by Rosenstock et al.1 and the accompanying editorial by Fiadjoe and Litman.2 Both publications confirm that flexible bronchoscopy “will still be required” and that anesthesiologists in “large number(s)… lack the commitment and desire to master fiberoptic intubation” and concluding that using a rigid videoscope represents a paradigm shift in anticipated difficult airway management is misguided. Indeed, in expert hands, not only was flexible bronchoscopy a reliable and efficient technique, equivalent in success rate and time to intubation to the McGrath video laryngoscope, but 7 of the 48 patients randomized to the McGrath video laryngoscope could not undergo the awake technique! The exclusion criteria (limited mouth opening and neck pathology prohibiting recurrent laryngeal nerve block via the transtracheal method) were also so restrictive that it is no surprise that the success rates of the two methods were equivalent. Head and neck pathology has already been associated with a high failure rate using video laryngoscopy.3 Perhaps any device chosen, including traditional Macintosh and Miller laryngoscopes, when this patient population was eliminated for investigation, would result in equivalent success. Given the fact that the success and time to perform an awake intubation was equivalent “in expert” hands, perhaps the recommendations should be that anesthesiologists and anesthesia trainees use flexible bronchoscopy more frequently to develop and maintain skills that require more practice and expertise rather than seek alternative and potentially limited devices that subjugate one’s required skillset. If we continue to compromise the development and maintenance of flexible bronchoscopic skills, future studies will inevitably demonstrate the superiority of the rigid devices in limited patient populations because of a lack of anesthesiologists who are skilled flexible bronchoscopists.
As clinicians and educators, we must squelch the desire to further encourage the steady erosion of advanced airway skills. Although we thank the authors for further demonstrating that video laryngoscopic methods have their role in managing patients with anticipated difficult airways, the need to perform awake flexible fiberoptic intubation is still an absolute vital skill that requires a renewed educational emphasis so that anesthesiologists can and will use this technique when indicated. Residency programs and airway workshops need to spend more time teaching the more difficult to master fiberoptic technique and less time teaching video laryngoscopy, which is easier to learn and maintain mastery of in the first place.
Adam I. Levine, M.D.,* Andrew B. Leibowitz, M.D.
*The Icahn School of Medicine at Mount Sinai, New York.
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1. Rosenstock CV, Thøgersen B, Afshari A, Christensen AL, Eriksen C, Gätke MR. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management: A randomized clinical trial. ANESTHESIOLOGY. 2012;116:1210–6

2. Fiadjoe JE, Litman RS. Difficult tracheal intubation: Looking to the past to determine the future. ANESTHESIOLOGY. 2012;116:1181–2

3. Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: An analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. ANESTHESIOLOGY. 2011;114:34–41

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