Date: 20 Oct 2009

Difficult tracheal intubation in randomized controlled studies: ethical considerations

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To the Editor,

We read with great interest the article by Thiboutot et al. published recently in the Journal.1 The authors evaluated the effects of manual in-line stabilization (MILS) of the cervical spine on the rate of difficult orotracheal intubation without cervical trauma in adult patients under general anesthesia. The study hypothesis was that the rate of failed tracheal intubation would be significantly greater with MILS than without. Although the results are convincing and the methodology seems correct, we believe this study raises an important ethical problem. While MILS is a maneuver frequently used while securing the airway of patients with a known or a potentially unstable cervical spine, its effect is known to impair visualization of the larynx with a reduction in the incidence of Cormack and Lehane’s grade 1 laryngeal visualization and an increased incidence of grades 2, 3, and 4.2 In Thiboutot et al.’s study, 50% of patients in the MILS group had an unsuccessful intubatio ...