Difficult airway: When deliberate is too close to improvisation.

Sir,

We read with interest the article by Kumar et al.[1] regarding a difficult airway rescue with the use of a modified open tracheostomy. The surgical airway is often used as a last resort for the rescue of a difficult airway. However, we would like to raise a few concerns about some critical points that the authors should have discussed in more detail:

They described a patient with a known obstructing airway presenting to the hospital with respiratory distress. The most appropriate strategies for a predicted critical airway with impaired ventilation could have been or should have at least been considered: An awake bronchoscopic intubation, an awake tracheotomy or cricothyrotomy.[2] Based on the computed tomography scan, [Figure 2 of the report] the cricothyrotomy approach was not advisable, and an awake tracheostomy could have been challenging given the patient's inability to maintain supine positioning; at this point an awake fiberoptic flexible bronchoscopy could have been considered. Instead, two unsuccessful attempts of direct laryngoscopy were performed. At this point, it would be useful to know whether or not the patient experienced hypoxia during all these attempts. Furthermore, moving a patient with airway compromise to an operating theatre during such a period could have further exacerbated hypoxia.[3]

A “planned” surgical tracheostomy was then attempted in the operating theater. A detailed explanation of why the surgeon was not able to perform the tracheostomy is not provided.

During tracheostomy attempts, face mask ventilation became increasingly difficult, and the anesthesiologist decided to proceed with multiple direct laryngoscopies. A supraglottic airway device could have been fitted to enable ventilation/oxygenation and access for fiberoptic guided tracheal intubation, avoiding repeated laryngoscopic attempts known to be associated with poor outcome.

Finally, a modified crico-tracheotomy was performed. How was the correct position of the tracheostomy confirmed?

In conclusion, the authors' key message that percutaneous tracheostomy has to be taken into consideration in a difficult airway is clinically rational, but based on their report not justifiable.[4] Besides the incidence of difficult cannula insertion/difficult dilation and failure to perform tracheostomy is low ranging from 15.5% to 4.9% depending on the technique used in elective conditions,[5] however in emergency situations multiple factors can aggravate the condition for a successful placement. In our opinion, this case provides important teaching points of common airway practices that are considered a failure in the required and clear airway strategy, including back-up plans in case of failure, limiting the number of intubation attempts to decrease the likelihood of airway trauma, effective preoxygenation to increase the time available to secure the airway before profound hypoxia occurs, availability of alternative techniques of laryngoscopy (e.g., videolaryngoscopy) to reduce the risk of a cannot intubate cannot ventilate scenario.

It is our opinion that is not the technique or device used, but the strategy adopted which is crucial in the management of an airway emergency (planning rather improvisation during escalating difficulty).

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Conflicts of interest

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