Carol A. Hirshman, M.D., Editor
Clinical Management of the Airway. First Edition. By J. T. Roberts. Philadelphia, W. B. Saunders, 1994. Pages: 507. Price:$60.00.
Since the publication of the results of the Closed Claims Study from the ASA Committee on Professional Liability, the continuing importance of the skillful management of the patient's airway has been reemphasized in the minds of all practicing anesthesiologists. However, those anesthesiologists who have turned to the literature for guidance in improving their practice have found a copious, dispersed, and contradictory body of published work, much of it anecdotal and of doubtful value. Several textbooks and manuals have been published during the last few years that have attempted to synthesize and present a coherent view of different aspects of this information, with mixed results. What is lacking is a well conceived and informed reference work.
Clinical Management of the Airway is a brave attempt to provide a comprehensive and authoritative view of every aspect of airway management. It is a lavishly illustrated multiauthored text with 59 contributors to 42 chapters, divided into four sections. The majority of authors are clinicians, and a majority of those are anesthesiologists. There are contributions from Canada, Germany, France, and the United Kingdom, but most of the contributors are associated with the Massachusetts General Hospital.
The first section is composed of two chapters covering functional anatomy and pathology of the airway. The anatomic description is competent, and the authors wisely rely on the classic illustrations from Gray's Anatomy, but although described, there is a strange dearth of illustrations of nerve distributions and the surface anatomy required to block them. Similarly, in the part devoted to laryngeal mechanics, there is no reference to the work of Fink and Demerest and the importance of the different laryngeal functions in the context of intubation of the larynx. The pathology chapter is comprehensive and concise but has only five photographs of block specimens, the remainder being photomicrographs. This might have been a good opportunity to relate what the anesthesiologist sees with the characteristics of the underlying pathology.
The second section, “Evaluating the Airway,” contains six chapters covering upper airway radiology, pulmonary function testing, clinical evaluation of the child (but not the adult), bronchoscopy, and sound studies. The radiology chapter is standard fare. There is no differentiation between the types of presentation of airway problems that may be evaluated safely in the radiology department and no mention as to what the intubationist may achieve with a C-arm image intensifier at the bedside. Again, what is lacking is the guidance to relate what can be seen by the anesthesiologist with the radiologic images. The chapter on pulmonary function testing is concise, but many anesthesiologists will remain skeptical concerning its place in the routine evaluation of the airway in the clinical situations they encounter. The chapter on bronchoscopy, both rigid and flexible, is written with a surgical diagnostic slant, but it contains a gem in its description of rigid bronchoscopy technique. The two chapters devoted to acoustic analysis of airways, although peripheral to airway management, are fascinating and well written.
The third section is composed of 17 chapters grouped under the heading of “Securing the Airway.” These cover a wide range of topics, including managing the airway outside the operating room, basic skills, equipment and techniques, the prediction of difficulty, and management of the failed intubation. Three chapters are devoted to fiberoptic topics, including the teaching of the skills required. The section concludes with two chapters devoted to extubation and the complications of intubation in general.
The final section also includes 17 chapters, this time addressing “Specific Airway Problems.” I recommend two unusual chapters as informative: that dealing with high frequency ventilation and the other devoted to modern airway appliances. Of the remainder, most cover their topics in appropriate detail. The chapter on “Airway Infections” is interesting but makes no attempt to offer guidance on the question as to when to delay surgery for treatment. A discussion of the implications of the modern surgical practice of routine prophylactic antibiotic coverage for operations and the effects of anesthesia on the infectious process would have been of value. The chapter on “Lasers and the Airway” is nicely done, but the chapter on the “Airway Management of the Cardiac Patient” seems to miss the point where the difficult airway is concerned.
The usual shortcomings of a multiauthored text are found here in abundance. There is a tremendous variation in depth, style, and quality between the contributions. Only 12 of the chapters lay claim to a single author. However, the main criticism is the book's lack of focus. The editor's preface claims that the work is designed to “help the clinician maximize successful management of airway problems,” but there is little evidence of a guiding philosophy of clinical management presenting the alternatives with critical evaluation of risk and utility. The reader is left with the same frustrations from contradictions and bald recommendations that will result from reviewing the original literature.
The anesthesiologic “meat” of this book is contained in the third section. Unfortunately, not all of it will be to everyone's taste. Some of the statements and recommendations are controversial. For instance, in chapter 23, dealing with teaching fiberoptic skills, the ASA Difficult Airway Algorithm is presented on page 259 and, on the following page, the authors make the sweeping claim that the clear message of the algorithm is that the patient with the known “difficult airway should be fiberoptically intubated awake.” Similarly, not all the “game plans” offered for different clinical scenarios in chapter 19 will be acceptable to practicing anesthesiologists. There is much duplication of material, particularly in terms of anatomy, airway evaluation, description of techniques, and extensive illustrations of double-lumen tubes. After a while, this becomes irritating to the reader. Some production errors are evident, such as the incorrectly captioned Figure 9(7), and the unwary will be in for a surprise if they try an oral intubation with the lightwand illustrated in Figure 9(5).
The achievement of this work is in the attempt. Unfortunately, this first edition fails to reach what might have been achieved with the available talent in the contributors list. Most of the chapters are informative and well referenced; therefore, a place in departmental libraries is warranted. My personal library will wait for the second edition.
Allan C. D. Brown, M.B., Ch.B., F.F.A.R.C.S., Associate Professor of Anesthesiology and Otorhinolaryngology, Director, Difficult Airway Clinic, University of Michigan, Ann Arbor, Michigan 48109.