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COMMENTARY
Year : 2021  |  Volume : 14  |  Issue : 4  |  Page : 466-467  

Indigenous intubation techniques using out of label devices: Boon or bane?


1 Department of Anesthesiology, Pain Medicine and Critical Care, DRBRAIRCH, New Delhi, India
2 Department of Onco-Anesthesiology and Palliative Medicine, DRBRAIRCH, AIIMS, New Delhi, India

Date of Submission27-Feb-2020
Date of Decision02-Mar-2020
Date of Acceptance24-Jun-2020
Date of Web Publication17-Jun-2021

Correspondence Address:
Nishkarsh Gupta
Department of Onco-Anesthesiology and Palliative Medicine, DRBRAIRCH, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_64_20

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How to cite this article:
Gupta A, Gupta N. Indigenous intubation techniques using out of label devices: Boon or bane?. Med J DY Patil Vidyapeeth 2021;14:466-7

How to cite this URL:
Gupta A, Gupta N. Indigenous intubation techniques using out of label devices: Boon or bane?. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Aug 4];14:466-7. Available from: https://www.mjdrdypv.org/text.asp?2021/14/4/466/318697



Airway management is an important skill for anesthesiologists, and failure to do so may be catastrophic.[1] The difficulties during intubation may be anticipated due to patient factors (beard, buck teeth, and restricted neck movements, etc.). There are many predictive tests that assess the airway for the difficulty and may predict the complexity, but their diagnostic accuracy is debatable.[2] In addition, there are other technical issues that are often ignored and make airway management challenges. These contributory factors may be related to the skill of anesthesiologists, availability/lack of equipment, difficulty with positioning, timing of the procedure, location of the hospital (nonoperating room intubations are more difficult), lack of technical personnel, etc.[3] A seemingly easy intubation in the presence of contributory factors listed above may increase the complexity/difficulty in intubation and lead to failure. Fiberoptic bronchoscope (FOB) is considered the gold standard for intubation in DA scenarios. Various guidelines for airway management have suggested that one should make alternative plans and strategies for intubation in patients anticipating failure. Furthermore, as per the plans, a DA cart consisting of a combination of definitive and rescue devices should be made. In resource-limited countries like ours, in the absence of FOB, anesthesiologists are often improvising on available equipment such as gastroscopes, nasal endoscopes, cystoscopies, etc., (of other specialties) for achieving successful intubation in complex airway scenarios.[4],[5] In fact, the first FOB guided intubation was done as early as 1967 by Peter Murphy using a choledochoscope.[6] However, these devices are not ideal, not commonly used for said purpose, and maybe effective selectively due to their dimensions (length and diameter) and, therefore, cannot have wide applicability and universal acceptance.

Rajmohan et al. have also innovated on the use of a pediatric gastroscope for intubation in patient for laparoscopic cholecystectomy in a patient with anticipated DA.[7] They have also described the use of a flexible cystoscope for intubation in a patient with unanticipated DA. These devices have working principle like FOB and an anesthesiologist trained in FOB should be able to use them for intubation. However since the devices have their limitations regarding the size of the endotracheal tube (ETT) that can be used (>7.5 mm ID with pediatric gastroscope), inappropriate length (shorter length in cystoscope required ETT shortening) and the absence of suction port (cystoscope). Since gastroscopes have a large diameter (8–14 mm) as compared to FOB, it is often difficult to load it with appropriate size ETT. Sindwani et al. have used a bougie to facilitate intubation through a gastroscope.[8] Similar problems were faced by the authors, and they could mount a size 8 ETT only on a pediatric gastroscope, which may limit its usefulness. Moreover, because of inexperience with the device for the said purpose, their use in unanticipated DA scenarios may be tricky and should be avoided. The use of alternative devices to facilitate tracheal intubation in the management of complex airway scenarios should be used with caution considering its limitations, especially when being used for the first time. In unanticipated intubation, there is always a time pressure in securing the ETT and use of an unfamiliar equipment at this time may be a perfect recipe for disaster and should be avoided. If unsuccessful, this technique would further add to the airway morbidity by increasing the number of attempts and airway edema or may even lead to bleeding, thereby converting a controlled situation to an emergency one. Availability and access of gastroscope or cystoscope at all locations is not possible, and therefore, its use in the emergency scenarios may not always be feasible. Some important features may be lacking in these device and with a larger (gastroscope) or smaller (cystoscope) working length, may be cumbersome to operate.

An institution equipped with advanced gastroscopes and cystoscopes should have a FOB as well, which is an invaluable device in anesthesiologist's armamentarium.

Another concern would be the sterility of such devices. Gastroscopes and cystoscopes do not have the stringent sterility requirements as that of a bronchoscope, and in an emergency scenario, sterility can be compromised.

In conclusion, the use of a device for an indication outside its routine use should only be attempted in exceptional circumstances like the malfunctioning of the recommended device, only in experienced hands and without compromising on patient safety.



 
  References Top

1.
Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth 2012;109 Suppl 1:i68-85.  Back to cited text no. 1
    
2.
Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists' prediction of difficult airway management in daily clinical practice: A cohort study of 188 064 patients registered in the Danish anaesthesia database. Anaesthesia 2015;70:272-81.  Back to cited text no. 2
    
3.
Cook TM, Woodall N, Frerk C, editors. Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society. In: Major Complications of Airway Management in the United Kingdom. Report and Findings. London: Royal College of Anaesthetists; 2011.  Back to cited text no. 3
    
4.
Sindwani G, Suri A, Shamim R. Oral gastroscope-guided bougie insertion and endotracheal intubation. Indian J Anaesth 2018;62:478-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Guzman JL. Use of a short flexible fiberoptic endoscope for difficult intubations. Anesthesiology 1997;87:1563-4.  Back to cited text no. 5
    
6.
Burkle CM, Zepeda FA, Bacon DR, Rose SH. A historical perspective on use of the laryngoscope as a tool in anesthesiology. Anesthesiology 2004;100:1003-6.  Back to cited text no. 6
    
7.
Rajmohan N, Nelson F, Upadhyay S. Unusual way of securing the airway using gastroscope and cystoscope as an alternative to fiberoptic intubation. Med J DY Patil Vidyapeeth 2021;14:91-3.  Back to cited text no. 7
  [Full text]  
8.
Sindwani G, Suri A, Shamim R. Oral gastroscope-guided bougie insertion and endotracheal intubation. IJA 2018;62:478-9.  Back to cited text no. 8
    




 

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