Use of the Airtraq® Laryngoscope

Mount Sinai Medical Center, New York, New York. steve.neustein@msnyuhealth.orgI read with interest the case report by Dhonneur et al. 1describing their use of the Airtraq® laryngoscope (AL; Prodol Meditec S.A., Vizcaya, Spain) in morbidly obese patients undergoing emergency cesarean delivery. I congratulate these authors on the incorporation of this recently introduced intubating device into their practice. However, there is surprisingly little discussion of the actual AL in their article.The AL is a disposable laryngoscope that allows viewing of the vocal cords without a straight line of sight from outside of the patient to the vocal cords. The AL light should be turned on approximately 1 min before use, to allow heating of the lens and to avoid fogging. The neck of the patient can be positioned in a neutral position. The curved blade is inserted in the center of the tongue. While looking through the viewer (or optional video), it is advanced further such that the epiglottis is identified, and the tip is placed into the vallecula. The handle is then lifted straight up to expose the vocal cords. The AL has a channel that is used to direct the tube through the vocal cords once visualization has been achieved. I have successfully used the AL, and one important difficulty that was not stated in the letter is that the tube may pass posteriorly as it leaves its guide, and further manipulation of the handle of the AL may be needed to allow the endotracheal tube to be successfully passed through the vocal cords.An important issue not discussed by the authors is the challenge of obtaining proficiency while at the same time controlling cost. The manufacturer recommends two to four uses before use in a patient with a difficult intubation. As in all techniques for intubation, there is a learning curve. ALs cost approximately $80 each and cannot be reused. This could pose a large expense to train an entire department and then maintain skills. It could also be a major ongoing expense if used frequently. If skills could be obtained in a simulator, the AL could be an important asset if kept on the difficult airway cart as a backup technique, but not used regularly. Obtaining the AL was discussed by our equipment committee but was not thought to be cost-effective for training an entire department, which has more than 100 members. Dhonneur et al. 1stated that the anesthesiologists had “performed the clinical learning process with the AL” but did not describe what this was; this information would have been helpful.The authors state that “There are only two validated airway devices allowing visualization of the glottis without alignment of oral and pharyngeal axes: the LMA CTrach (SEBAC, Pantin, France) and the AL.” This is not true; there are multiple such laryngoscopes now available. The Glide scope (Saturn Biomedical, Burnaby, British Columbia, Canada) is a nondisposable video laryngoscope that is easy to use and allows visualization of the vocal cords without alignment of the axes. The endotracheal tube is held in the right hand and can be manipulated independently from the laryngoscope. The first laryngoscope developed, which combined fiberoptic viewing with a curved rigid blade, was the Bullard laryngoscope (Circon ACMI, Stamford, CT).The authors also stated that the Sellick maneuver was applied before induction; this would potentially be uncomfortable for the patient. The cricoid should be palpated before induction, but the actual cricoid pressure should not be applied until the patient is starting to fall asleep. It has been recommended to apply 10 N (1 kg) of pressure as the patient is falling asleep and increase to 30 N after the patient becomes unconscious.2Mount Sinai Medical Center, New York, New York. steve.neustein@msnyuhealth.org

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