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To the Editor,
We thank Drs Mirrakhimov and Torgeson for their interest in our article and appreciate the opportunity to respond.1 As observed in their letter, we found that a decrease in the use of awake tracheal intubation (ATI) had occurred during the years 2014–2020 at our institution.2 This contrasted with a previous study we had published that looked at the years 2002–2013, in which we did not observe any decrease in the use of ATI (despite increasing use of videolaryngoscopy [VL]).3 Regardless, any role of VL in decreasing the use of ATI will likely never be more than an observed association, rather than proven causation. Introduced in the early 2000s, if increasing use of VL is indeed found to be associated with decreasing use of ATI, the differing findings of our two studied time periods might suggest a latency of one to two decades before clinicians had developed sufficient trust in the efficacy of VL to decrease their use of ATI.
Drs Mirrakhimov and Torgeson advocate for the need to maintain skills in flexible endoscopy for the purpose of ATI, and we wholeheartedly agree. Nonetheless, as illustrated by their cited article by Rosenstock et al.1,4 and a subsequent meta-analysis on the topic by Alhomary et al.,5 one cannot ignore the evolving evidence that VL can be used for ATI in select topically anesthetized and sedated difficult airway patients. Thus, once a decision for ATI has been made, and assuming equally effective airway topicalization and systemic medication administration either way, the best device for the ATI itself must then be determined: flexible endoscopy or VL. We submit that salient considerations in that determination might include: 1) the patient’s presenting anatomy (some presentations may preclude access to the mouth with a VL blade; others may require a flexible endoscope during tracheal intubation to assess the lower airway for penetrating injury, as two examples); or 2) given that some of the most difficult anatomic presentations (e.g., severely limited mouth opening and pathologically enlarged or superiorly displaced tongue) often require nasal flexible endoscopic ATI, the clinician may elect to perform all ATIs with flexible endoscopy to help maintain skills with the device. Conversely, other presentations might easily allow for use of either device (e.g., the critically ill patient with no anatomic predictors of technical difficulty undergoing ATI chiefly to avoid exacerbating adverse physiology). Finally, certain presentations managed with a “niche” technique might require the use of VL during ATI, e.g., placement of a very small tracheal tube though a highly obstructed laryngeal inlet.6
Ultimately, provided the clinician has adequately thought through a decision on which device to use and is prepared with a plan should the technique be unsuccessful, it is likely that VL can safely be used for at least some clinical presentations that require ATI.
References
Mirrakhimov AE, Torgeson E. Awake tracheal intubation: what can be done to maintain the skill? Can J Anesth 2023; https://doi.org/10.1007/s12630-023-02476-5
Law JA, Thana A, Milne AD. The incidence of awake tracheal intubation in anesthetic practice is decreasing: a historical cohort study of the years 2014–2020 at a single tertiary care institution. Can J Anesth 2023; 70: 69–78. https://doi.org/10.1007/s12630-022-02344-8
Law JA, Morris IR, Brousseau PA, de la Ronde S, Milne AD. The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: an historical cohort study. Can J Anesth 2015; 62: 736–44. https://doi.org/10.1007/s12630-015-0387-y
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. https://doi.org/10.1097/aln.0b013e318254d085
Alhomary M, Ramadan E, Curran E, Walsh SR. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis. Anaesthesia 2018; 73: 1151–61. https://doi.org/10.1111/anae.14299
Kristensen MS, de Wolf MW, Rasmussen LS. Ventilation via the 2.4 mm internal diameter Tritube® with cuff – new possibilities in airway management. Acta Anaesthesiol Scand 2017; 61: 580–9. https://doi.org/10.1111/aas.12894
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Funding statement
J. Adam Law is funded for academic time by the Dalhousie University Department of Anesthesia, Pain Management & Perioperative Medicine.
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This submission was handled by Dr. Stephan K. W. Schwarz, Editor-in-Chief, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.
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Law, J.A., Thana, A. & Milne, A.D. In reply: Awake tracheal intubation: what can be done to maintain the skill?. Can J Anesth/J Can Anesth 70, 1270–1271 (2023). https://doi.org/10.1007/s12630-023-02477-4
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DOI: https://doi.org/10.1007/s12630-023-02477-4