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Re: RSI and crichothyrotomy success rates

Dear Editor

A paper by Mizelle et al. found that (in the USA)success rates for prehospital:
- RSI by non physicians varied from 76%-98%
- Crichothyrotomy by non physicians varied from 0%-4%

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Re: Failed intubation drill: a necessity

Dear Editor

As an anaesthetist, I read with interest the article by Carley and colleagues regarding the necessity of having a drill for failed intubation in the Emergency Department. A drill is essential and should be actively taught and practised.

The algorithm you have developed is very similar to those used in anaesthetic practice, but I wish to highlight a few points. The use of the gum-elastic bougie should feature earlier in the algorithm. There are groups that use it routinely for all intubations.[1,2] The gum-elastic bougie is a great asset and is often underrated as a piece of equipment by non-anaesthetists. Its routine use may decrease the frequency that the failed intubation drill is required. It is usual that the first laryngoscopic view is the best view so it is sensible to optimise the chance of success at this stage.

My second point involves your suggested use of the laryngeal mask airway (LMA). It has been shown to be a reasonable aid to airway management for non-anaesthetists or those inexperienced in its use in resuscitation. With appropriate education, its application is considered relatively easy to learn. It is a less invasive, simpler and considering the rarity of cricothyroidotomies, should routinely be used in the algorithm before proceeding to the cricothyroidotomy. The LMA has been shown to be a suitable choice for temporary airway control when intubation fails.[3]

The ProSeal, a new laryngeal airway device may have a place in the Emergency Department. It has a port to allow easy passage of an orogastric tube. It has been compared with the LMA in anaesthetised, non-paralyzed patients. The ProSeal is more difficult to insert but forms a better seal and does aid the prompt passage of an orogastric tube.[4,5] It may provide a temporary airway that allows the redirection of regurgitated fluid away from the respiratory tract.[6,7] The possibility of regurgitation cannot be excluded fully and thus the ProSeal cannot replace an endotracheal tube.

Finally, the BURP technique or optimal external laryngeal manipulation has been shown to be the most effective with pressure applied to the low thyroid cartilage.[8] It must not be confused with cricoid pressure.

It is essential to have a failed intubation drill in any location that tracheal intubation is being undertaken. More importantly, it is necessary to teach methods to optimise intubating conditions, including patient positioning, having appropriate personnel present, being proficient in the use of equipment and having all necessary equipment checked and available.

References

(1) London Helicopter Emergency Medical Service Standard Operating Procedures: Rapid sequence induction.

(2) Careflight Prehospital Trauma Course.

(3) Martin SE, Ochsner MG, Jarman RH, Agudelo WE, Davis FE. Use of the laryngeal mask airway in air transport when intubation fails. J Trauma 1999;47:352-7.

(4) Brimacombe J, Keller C, Fullekrug B, Argo F, Rosenblatt W, Dierdorf SE, Garcia de Lucas E, Capdevilla X, Brimacombe N. A multicentre study comparing the ProSeal and Classic laryngeal mask airway in anesthetized, nonparalyzed patients. Anesthesiol 2002;96: 289-95.

(5) Cook TM, Nolan JP, Verghese C, Strube PJ, Lees M, Millar JM, Baskett PJF. Randomized crossover comparison of the ProSeal with the classic laryngeal mask airway in unparalysed anaesthetized patients. BJA 2002;88:527-33.

(6) Keller C, Brimacombe J, Kleinsasser A, Loeckinger A. Does the ProSeal laryngeal mask airway prevent aspiration of regurgitated fluid? Anesth Analg 2000;91:1017-20.

(7) Brimacombe J, Keller C. Airway protection with the Proseal laryngeal mask airway. Anaesth Intensive Care 2001;29:288-91.

(8) Benumof JL, Cooper SD. Quantitative improvement in laryngoscopic view by optimal external laryngeal manipulation. J Clin Anesth 1996;8:136-40.

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Re: RSI by non-anaesthetists in the UK - lower incidence of cricothyrotomy than in the US

Dear Editor

Dr Carley and colleagues have produced invaluable and highly practical failed intubation guidelines for emergency physicians using RSI. They highlight the emergency department cricothyrotomy rate in the United States of 0.5-1.2%, and the lack of comparative United Kingdom rates, which are thought to be lower.

As part of a prospective study of emergency airway management by intensive care doctors in a large UK district general hospital, we examined 208 consecutive emergency rapid sequence intubations outside the operating theatre, of which 76 were performed in the emergency department. There were no cricothyrotomies, no failed intubations, and no deaths during the procedure even though the intubating physicians were of varying seniority, with career backgrounds in emergency medicine and general medicine as well as anaesthesia. This suggests that, with proper training and support, even junior doctors in A&E can undertake RSI with a low risk of failure requiring an emergency surgical airway.

We agree that as long as such crucial training and senior support are provided, UK emergency department patients will continue to experience lower rates of cricothyrotomy and failed intubation than in the United States. This will be necessary if RSI by non-anaesthetists is to become widely accepted in the UK. The guidelines by Dr Carley et al are an important contribution to this process.

Dr Cliff Reid
Registrar in Paediatric critical care
Childrens Hospital Westmead
New South Wales
Australia

Dr Louisa Chan
Registrar in emergency medicine
Gosford District Hospital
New South Wales
Australia