Current Difficult Airway Management: Not Good Enough!: Reply

We appreciate the comments of Drs. Marymont and Vender¹  on our recent Editorial²  addressing the article on a closed claims analysis of difficult tracheal intubation.³  Drs. Marymont and Vender are concerned because our statement in the Editorial²  that “[i]f difficult airway management is predicted, general anesthesia should not be induced before securing the airway” may be inconsistent with the American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.⁴ 

Although our remarks were orientated to an article³  centered on difficult tracheal intubation, our statement regarding securing the airway before induction of anesthesia does not necessarily mean awake tracheal intubation. We prefaced the statement as follows: “It is apparent from these cases that inadequate planning is a core issue. The airway must be assessed preoperatively, not only to predict difficult intubation, but also the risk of difficulty in ventilation through a facemask or supraglottic airway, difficulty in securing a surgical airway and risk of aspiration.”²  Clearly, there must be a degree of certainty regarding capacity to “secure the airway” in the unconscious patient (be it by use of a facemask, supraglottic airway, invasive airway, or tracheal intubation) before deciding to induce general anesthesia first. Hence, our statement, which does not mandate intubation before general anesthesia, is not inconsistent with the practice guidelines formulated by the American Society of Anesthesiologists.⁴ 

Our Editorial²  accompanied a compelling article³  that points out that outcomes regarding management of difficult tracheal intubation remain poor despite the considerable ongoing efforts by professional bodies and others to improve them. The main message of our editorial is that we should work together “to lift standards in crisis management for airway difficulties . . . much as has been done for cardiopulmonary resuscitation in recent years.”²  To achieve this, “we need to regularly review the guidelines and encourage further research in relationship to these problems.”²  In addition, we pointed out that “knowledge of guidelines alone is insufficient to address these problems: skill and judgment are essential ingredients.” Therefore, we also need to establish a system, “with crews [i.e., we clinicians] undergoing regular, systematic simulation training and emergency equipment constantly to hand and regularly checked.”²  Only through these steps can we progress toward risk-free airway management.

Dr. Hillman has received institutional grants from ResMed Inc. (San Diego, California), Nyxoah (Mont-Saint-Guibert, Belgium), Oventus (Indooroopilly, Australia), and Zelda Therapeutics (Perth, Australia). Dr. Asai reports no competing interests.