Difficult tracheal intubation

L ARYNGOSCOPY began in the 1800s with indirect attempts to visualize the glottis, from Bozzini’s mirror clad speculum powered by candlelight, to the singer Manuel Garcia’s successful visualization of his own larynx. In the 1900s, Chevalier Jackson, Miller, and Magill pioneered the era of direct laryngoscopy. In the 1960s the flexible fiberoptic bronchoscope was established as the gold standard for difficult airway management because of its ability to be manually manipulated and see around corners. A careful examination of modern medical equipment reveals few vestiges of previous eras. The iron lung gave way to modern ventilators; laparoscopy transformed open surgery, and now is being transformed by robotics. Despite the rapid transformation of medicine by technological advances, laryngoscopy and airway management have remained essentially the same, until now. About his invention, Bozzini’s colleagues remarked, “premature conclusions were likely to be arrived concerning the instrument, perhaps even there may be an outlay of money which might afterward be regretted.” Little did they know that the quest to visualize the larynx would come full circle, and we would return to his design ideas more than a century later. In this issue of ANESTHESIOLOGY, Rosenstock et al. compared standard fiberoptic intubation with video laryngoscopic intubation in sedated patients with anticipated difficult airway management. Their results confirm anecdotal evidence that video laryngoscopy facilitates intubation in patients with challenging airways, and can be useful in the nonanesthetized patient. The introduction of video and optically enhanced laryngoscopes designed for indirect visualization of the larynx represents a reaffirmation of the pioneers of laryngoscopy. Rosenstock et al. performed a multicenter randomized comparison of the McGrath video laryngoscope (Aircraft Medical, Edinburgh, Scotland, United Kingdom) to the flexible fiberoptic bronchoscope. They tested the hypothesis that, in experienced hands, intubation with the McGrath video laryngoscope would be faster than flexible bronchoscopy. They found no differences in intubation time and success rate. Furthermore, they established the utility of the McGrath video laryngoscope for intubation in nonanesthetized patients, and showed that levels of discomfort were similar for both techniques. The patients in this study received topical anesthesia with lidocaine spray as well as transtracheal injection of lidocaine, and were sedated with a remifentanil infusion titrated to a Ramsay score of 2–4. Although many anesthesiologists administer sedatives during awake intubation, flexible bronchoscopy can be performed without any sedation with adequate topical anesthesia. This is because the thin fiberoptic bronchoscope can be gently manipulated around airway structures. This approach is particularly useful in patients in whom sedation may pose a significant risk of upper airway obstruction. Since distraction of airway structures (e.g., tongue) may be necessary for adequate glottic visualization with video laryngoscopes, future studies should determine if video laryngoscopic intubation is possible without sedation. Nevertheless, the Rosenstock study represents a challenge to our accepted paradigm of airway management and a turning point in the thinking about the best tool to secure a difficult airway. They demonstrate that a video laryngoscope may be a useful alternative in awake intubation. From our involvement in airway education workshops, we have observed that a relatively large number of anesthesiologists lack the commitment and desire to master fiberoptic intubation. This relates to the protracted learning curve to acquire the necessary psychomotor skills, procurement and cleaning costs, and the time pressure in the operating room. In contrast, video laryngoscopes are easy to learn, readily portable, and can be quickly readied for subsequent intuba-