Intubation by using exaggerated curve: A modification of technique for underprivileged area.

Sir,

The present letter is an independent observation and modification of the technique of endotracheal intubation as a practitioner we use on day to day basis. I would like to attract your attention toward the common situation encountered in airway management leading to patient mortality that is unable to intubate. Today also the most challenging task for anesthesia care provider is management of difficult airway. Though we have variety of airway equipment available still the most common method of securing airway is by traditional method through direct laryngoscopy across the spectrum of health care. Incidence of difficult intubation has been reported to be approximately 1.5–8%.[12] Difficult intubation is defined as when multiple laryngoscopies, maneuvers and or blades used by an experienced airway practitioner fails to secure airway. A common factor preventing successful tracheal intubation is the inability to visualize the vocal cords during the performance of direct laryngoscopy. Cormack and Lehane originally defined and gave grading system for laryngoscopic view of airway.[3] Many devices and techniques (bougie, stylet, video larygoscope) are now available to circumvent the problems typically encountered with a difficult airway using conventional direct larygoscopy. Thus the overall morbidity and mortality associated with difficult airway in both acute and surgical setting has been significantly reduced.[2] However the use of these devices are subject to their availability at different centers.

Intubation is a very important aspect of emergency management. At times, an encountered difficult intubation can be fatal with the unavailability of assisting equipment in situation occurring outside hospital or in a remote area costing patient's life.

A simple modification of technique can be useful in this situation. In our technique, we are exaggerating the already present Magill curve of endotracheal tube (ETT). To achieve this, simple maneuver of connecting both ends of tube is used [Figure 1]. During laryngoscopy when difficult intubation is suspected (i.e. Cormack and Lehane classification Grades 3 and 4) the tip of this modified curved ETT is placed below the epiglottic tip and with the twisting wrist movement as in supination and pronation movement the ETT is placed upward in a fashion to reach trachea. The exaggerated curve tip prevents the esophageal intubation as it tends to go upward only. Sellick's maneuver can also be used to visualize tip in Grade 4 Cormack and Lehane.[4]

Figure 1

(a) Exaggeration of Magills curve by joining the ends, (b) wrist movement

After obtaining the approval from the Hospital Ethics Committee and written informed consent from the patient, we did pilot study over the period of 2 months in all the cases done in our operation theatre under general anesthesia which required. During this period in total 60 cases done under general anesthesia, we encountered eight cases with Cormack and Lehane Grades 3 and 4. We attempted intubation by direct larygoscopy taking all precaution like putting pillow below head, etc. ETT which was used for intubation was curved by connecting its both end. In six cases, airway was secured successfully in first attempt. In two cases, we could not put tube in three attempts, there we used classical laryngeal mask airway to secure airway.

We suggest this technique as a rescue in situations where difficult airway is encountered and availability of advanced airway is not possible. We need to conduct a clinical trial with a large sample size to get this technique established.

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Conflicts of interest

There are no conflicts of interest