To the Editor:
I recently used the Augustine Guide Trademark and was interested in the study of the clinical use of the Augustine Guide Trademark by Carr and Belani . The authors did not, however, attempt to define the role of the guide in current practice. They used the guide in 100 patients, were unable to intubate the trachea in six patients (after three attempts), and had difficulty in another 23 (successful intubation with second or third attempt). The tracheas of the patients with six failures were all intubated using direct laryngoscopy.
Although no comparison was made between direct laryngoscopy and use of the guide, perhaps endotracheal intubation is more likely to be successful (and faster) with a laryngoscope than the guide. Logically then, the guide should be used where direct laryngoscopy and endotracheal intubation have failed. Furthermore, the 18% incidence of minor injuries, of which 39% were small lacerations, is disturbing.
The authors do not state the distribution of difficult and failed cases, i.e., whether they were clustered in the early part of the study or evenly distributed throughout the study. In eight cases there was difficulty with inserting the guide into the patient's mouth. (All patients had a normal mouth opening.) In my limited experience, the mouth opening has to be near normal for easy insertion of the guide.
My initial impressions are that the Augustine Guide Trademark may be used (a) where direct laryngoscopy and intubation have failed and patient oxygenation is assured and (b) in situations where cervical spine mobility is limited or needs to be limited. It can only be used in adults with size 7.0-8.0 endotracheal tubes. The manufacturer does not recommend its use in patients with tumors or abscesses of the upper airway. On the question of training in its use, one has to consider its cost as a single-use product and its potential to be more traumatic to the upper airway than direct laryngoscopy. Close supervision of trainees and the avoidance of excessive forces are essential.
A plastic version of the "divided oropharyngeal airway" was described in 1977 by Berman . Its distal end is meant to sit in the vallecula. The endotracheal tube is passed blindly through the airway, which is then split into two halves and removed. No stylet is used.
Rajesh P. Haridas, MBChB (Natal), FANZCA
Department of Anaesthetics, Faculty of Medicine, University of Natal, Congella 4013, South Africa
1. Carr RJ, Belani KG. Clinical assessment of the Augustine Guide Trademark for endotracheal intubation. Anesth Analg 1994;78:983-7.
2. Berman RA. A method for blind oral intubation of the trachea or esophagus. Anesth Analg 1977;56:866-7.