James C. Eisenach, M.D., Editor.

Fiberoptic Endoscopy and the Difficult Airway, 2nd edition. By Andranik Ovassapian. Philadelphia, Lippincott-Raven, 1996. Pages: 304. Price:$135.00.

Andranik Ovassapian's Fiberoptic Endoscopy and the Difficult Airway is a revised and augmented edition of his 1990 Fiberoptic Endoscopy in Anesthesia and Critical Care. The targeted audience includes anesthesiologists, emergency medicine physicians, critical care specialists, otolaryngologists, and trauma surgeons. I believe the information presented in the book is of great benefit to its intended audience.

Of the 15 chapters, 5 are new and 8 are rewritten. The publication makes excellent use of graphics that impart the message more effectively than text can. Numerous black and white drawings are accompanied by high quality color photographs that picture the various anatomic and technologic aspects of this subject. The writing is concise with little of the extraneous text or redundancy found in some textbooks written by multiple authors. The index is detailed enough to provide ease of finding specific topics.

The outline of the book progresses logically, starting with the basics of the fiberoptic scope, the pertinent anatomy and physiology, and radiologic assessment of the airway. Preparation of the patient's airway with topical anesthesia is then thoroughly discussed. This discussion is essential and extremely helpful, considering the greater efficiency with which fiberoptic endoscopy is performed after proper airway preparation. Likewise, Dr. Ovassapian discusses the various techniques of airway anesthesia and their relative benefits and drawbacks.

Much of the chapter on conscious sedation is a primary text discussing the general subject and is not well designed as a discussion of sedation specifically for fiberoptic endoscopy. For example, although the use of propofol, midazolam, and fentanyl are well discussed, some other pharmacologic agents that clinicians may find helpful are not (e.g., ketamine, droperidol). Following are chapters dealing with various aspects of the topic such as the adult, obstetric, and pediatric airways, bronchial endoscopic techniques, and critical care endoscopy. Important clinical teaching gems that are often overlooked by practitioners (e.g., “this [jaw thrust] maneuver is vital, constituting the most important step in fiberoptic intubation under anesthesia.”) are included throughout these chapters. Subsequent chapters deal with the difficult airway, with updated areas such as endoscopy using the laryngeal mask airway (LMA) and esophageal airways. Although the LMA is given a specific chapter (which is good), the previous chapter dealing with management of the difficult airway mentions the LMA sparingly, and because the textbook was published in 1996, the older (1993) ASA algorithm, which does not incorporate the LMA, is displayed.

In addition, extubation of the difficult airway, an area relatively unexamined by other writers, is given careful and detailed commentary. Dr. Ovassapian concludes his book by demonstrating his competency as a teacher with the chapter “Learning Fiberoptic Intubation Techniques.” Even the most inexperienced practitioner, after reading this chapter and using some guided instruction, should be able to perform airway endoscopy with greater confidence.

In summary, Dr. Ovassapian's new textbook is a valuable addition worth its price to any operating room or intensive care unit bookshelf because of its unique and well-constructed content. It is not without significance that the “A” in ABC (airway, breathing, circulation) comes first. When confronted by the rare difficult or compromised airway, it is of critical importance that the clinicians be as well educated as possible in the evaluation and management of this subject.

Timothy N. Harwood, M.D.

Assistant Professor; Department of Anesthesiology; Bowman Gray School of Medicine; Winston-Salem, North Carolina 27157–1009