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CANADIAN JOURNAL OF ANESTHESIA

Correspondence
Critical arrhythmia associated with
pulmonary artery catheterization in
a parturient with severe pulmonary
hypertension
To the Editor:
Despite advances in pharmacological management of
pulmonary hypertension (PHTN), parturients with
PHTN have a maternal mortality of 3036%.1 The use
of pulmonary artery catheters (PAC) for monitoring
these patients intraoperatively remains controversial,2
and the PAC may convey no benefit compared to
traditional management.3 Significant arrhythmias can
occur in 4387% of patients during pulmonary artery
catheterization.4 Structural changes and enlargement
of the right atrium may also predispose patients with
PHTN to arrhythmias, and more often these patients
suffer marked clinical deterioration with arrhythmias.5
A patient with PHTN in our recent care experienced
the potential detrimental effects of PAC monitoring
during the course of Cesarean delivery (CD) under
regional anesthesia.
A 27 yr-old G2P1 parturient presented at 28 weeks
gestation with two weeks of worsening dyspnea. A
computerized tomography scan was negative for pulmonary embolism, but revealed a dilated pulmonary
artery and right ventricle. Subsequent right heart
catheterization showed a probable sinus venosus
and atrial septal defect [pulmonary artery pressure =
82/34 mmHg, pulmonary vascular resistance (PVR)
= 600 dynsec1cm5]. Medical optimization prior
to delivery was achieved with sildenafil and inhaled
iloprost. Elective CD occurred at 32 weeks gestation. Following the introduction of a right internal
jugular sheath, a PAC was inserted uneventfully with
the patient supine. The patient then sat upright for
placement of a combined spinal-epidural. She received
1 mL of 0.75% bupivacaine, fentanyl 15 g, and morphine 100 g intrathecally. The patient then lay supine
with left uterine displacement, and was prepared for
placement of femoral arterial and venous introducer
catheters under local anesthesia. The femoral introducer catheters were placed prophylactically such that
femoral-femoral bypass could be instituted with minimal delay should it become necessary.

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Approximately nine minutes after the spinal dose,

the electrocardiogram revealed a paroxysmal atrial
tachycardia with multiple premature ventricular complexes associated with a systolic blood pressure measuring 60 mmHg. Her blood pressure recovered with
epinephrine and cautious fluid boluses, but the atrial
arrhythmia persisted. It was suspected that the PAC
was no longer in the pulmonary artery and the balloon may have dislodged into the right ventricle and
then atrium, initiating the arrhythmia and profound
hypotension. The PAC was withdrawn, at which
point normal sinus rhythm was restored. The CD
was uneventful and a premature infant was born with
Apgar scores of 5 and 7 (weight = 1910 g).
The use of regional anesthesia in parturients with
cardiovascular disease avoids the potential myocardial depressant effects of general anesthesia. Newer
pulmonary vasodilators such as sildenafil and inhaled
iloprost allow for medical optimization with minimal
side effects, without interfering with the conduct of
regional anesthesia. Whether one chooses regional
or general anesthesia, the use of invasive hemodynamic monitoring with a PAC in parturients should be
patient-selective. This case demonstrates the arrhythmogenic potential of PACs, particularly in patients
with irreversible pulmonary arterial hypertension and
a fixed PVR. The PAC catheter may become displaced
during movement in patients under regional anesthesia. Therefore, it may be prudent to site the PAC
after the regional technique has been established, or
alternatively, to perform the regional procedure in the
lateral decubitus position, which may limit subsequent
displacement of the PAC. Finally, less invasive monitoring may be considered.
Ronald B. George MD FRCPC
Adeyemi J. Olufolabi MB BS DCH FRCA
Holly A. Muir MD FRCPC
Duke University Medical Center, Durham, USA
E-mail: ronald.george@duke.edu
This letter was supported solely by departmental
funding.
Accepted for publication March 2, 2007.

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CORRESPONDENCE

References
1 Weiss BM, Zemp L, Seifert B, Hess OM. Outcome of
pulmonary vascular disease in pregnancy: a systematic
overview from 1978 through 1996. J Am Coll Cardiol
1998; 31: 16507.
2 Smedstad KG, Cramb R, Morison DH. Pulmonary
hypertension and pregnancy: a series of eight cases.
Can J Anaesth 1994; 41: 50212.
3 Sandham JD, Hull RD, Brant RF, et al.; Canadian
Critical Care Clinical Trials Group. A randomized,
controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003;
348: 514.
4 Ermakov S, Hoyt JW. Pulmonary artery catheterization.
Crit Care Clin 1992; 8: 773806.
5 Tongers J, Schwerdtfeger B, Klein G, et al. Incidence and
clinical relevance of supraventricular tachyarrhythmias
in pulmonary hypertension. Am Heart J 2007; 153:
12732.

Angled or curved stylet for intubation

with the GlideScope?
To the Editor:
I read with interest the study by Jones et al. evaluating effect of stylet angulation and endotracheal tube
(ETT) camber on time to intubation (TTI) with the
GlideScope (GVL; Verathon Medical Inc., Bothell,
WA, USA).1 I commend the authors for their interesting study and comment on two aspects of the report.
The authors state that they compared 90o vs 60o
angled stylets. The Figure in their manuscript displays two styletted ETTs studied. The first ETT has a
straightforward shape with a 90o stylet angle. However,
the second ETT gives the impression that the stylet was
curved rather than angled, and that the angle within
the curve is 90o and not 60o. The authors modeled this
stylet by matching the angulation of the distal half of
the GVL blade first (Figure A). At this stage, the stylet
resembles the 60o stylet recommended by the manufacturer (Figure B).2 The authors then added at least
30o of angulation by reproducing the proximal half
of the GVL blade (Figure C). Even though the most
distal part of this stylet has a 60o angulation, the angle
contained within this stylet is a 90o angle. The logic
for this lies in the differential positioning between the
GVL blade and the stylet. The glottic view is obtained
and the GVL blade is held static within the vallecula.
The stylet is advanced alongside the blade until the tip
reaches the glottis, which is in front of the GVL blade.
This gives the impression that both the distal and
proximal parts of the stylet curve are actively used in
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FIGURE A) The initial 60 o stylet angulation. Two tangential lines, one along the shaft and the other along the
distal part of the endotracheal tube (ETT) cur vature form
a 60 o angle. B) An ETT is loaded with the manufacturers
rigid steel stylet [GlideScope (GVL - ST1), Verathon
Medical Inc., Bothell, WA, USA]. This stylet is cur ved at a
60 o angle. C) The cur ved stylet resembles the entire GVL
blade, as used in the study. 1 Two tangential lines form a
90 o angle.

the process of tracheal intubation. Therefore I believe

that the authors actually studied the difference in TTI
between a 90o angled and a 90o curved stylet.
My second comment relates to the experience mix
of the anesthesiologists who performed tracheal intubations with the GVL. In the 90o group, 76% of operators were experienced and 24% were not.1 In the 60o
group, 65% of operators were experienced and 35%
were not. In the absence of TTI for the experienced
and non-experienced operators within each group, it
is possible that the 13% reduction in the TTI in the
90o group could have been due in part, to the greater
experience of operators in that group. It would be
interesting to know the TTI for both the experienced
and non-experienced operators. These additional data
may help guide future investigators when planning
similar studies.

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CANADIAN JOURNAL OF ANESTHESIA

Mirsad Dupanovic MD
University of Rochester, Rochester, USA
E-mail: Mirsad_Dupanovic@URMC.Rochester.edu
Accepted for publication February 7, 2007.
References
1 Jones PM, Turkstra TP, Armstrong KP, et al. Effect
of stylet angulation and endotracheal tube camber
on time to intubation with the GlideScope. Can J
Anesth 2007; 54: 217.
2 The GlideScope Video Intubation System Operator
and Service Manual. Available from URL; http://
www.virox.com/protocols/pdf/ManufacturersGlideSc
opeManual.pdf (accessed January 26, 2007).

Reply:
We thank Dr. Dupanovic for his interest in our study.
As mentioned in our manuscript,1 we chose the two stylet
angles to be studied based on the most common angulations used by anesthesiologists in our local practice. The
distal 60 angulation used at our centre and in the
study was heavily influenced by an expert in airway
management who described using a stylet shape that
closely approximates the shape of the GlideScope blade.2
We believe that these are clinically relevant stylet angulations that merit comparison to each other. Based on our
study and the observations of others,3 we believe that the
initial stylet configuration for orotracheal intubation
using the GlideScope should be 90, as described in
detail in our study.
We agree that experience is a potential confounding
variable in airway instrumentation research, and this
emphasizes the importance of randomization to equally
distribute potential known or unknown confounders
among the groups being studied. Since analyzing times
to intubation (TTI) based on experience was not a prespecified secondary outcome (and is therefore subject
to the perils related to subgroup analysis),4 it was with
hesitance and caution that we re-analyzed the data to

TABLE Comparison of 90 and 60 degree groups by level

of experience
Comparison

Mean difference
(95% confidence interval
of difference)

90 experienced vs
- 0.01 sec (-14.85 to 14.83)
> 0.05
90 inexperienced
60 experienced vs
-17.1 sec (-30.6 to -3.6)
< 0.01
60 inexperienced
One-way ANOVA with Tukey-Kramer post test. Calculated in
GraphPad Prism version 4.03 for Windows.

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see if experience improved times to intubation in either

the 90 or 60 groups (Table). Interestingly, experience
of the operator did not seem to influence TTI in the 90
group, but markedly influenced TTI in the 60 group.
If anything, this would tend to confirm the conclusion
that the 90 stylet configuration is superior to the 60
configuration, especially when dealing with an inexperienced practitioner performing tracheal intubation with
the GlideScope videolaryngoscope.
Philip Jones MD FRCPC
Timothy P. Turkstra MD FRCPC
Christopher Harle MBChB FRCA
Kevin Armstrong MD FRCPC
London Health Sciences Centre University
Hospital, London, Canada
E-mail: philip.jones@lhsc.on.ca
References
1 Jones PM, Turkstra TP, Armstrong KP, et al. Effect
of stylet angulation and endotracheal tube camber
on time to intubation with the GlideScope. Can J
Anesth 2007; 54: 217.
2 Cooper RM. Videolaryngoscopy in the management of
the difficult airway (letter reply). Can J Anesth 2004;
51: 956.
3 Doyle DJ. Awake intubation using the GlideScope
video laryngoscope: initial experience in four cases. Can
J Anesth 2004; 51: 5201.
4 Oxman AD, Guyatt GH. A consumers guide to subgroup analyses. Ann Intern Med 1992; 116: 7884.

Airway management for intra-oral

surgery - airway rst!
To the Editor:
We read with interest the airway management of a
patient with an intra-oral dermoid cyst as described
by Raveenthiran and colleagues.1 While the authors
should be congratulated for their successful management of an anticipated difficult airway, we seek some
clarifications from them. The aspiration of contents
of any oral swelling should be preceded by appropriate radiological evaluation, which has not been mentioned. It is not clear whether the large size of the
needle used required local or topical anesthesia. It is
also not clear if the aspiration was carried out using an
extra-oral (e.g., submental) approach. Furthermore,
these authors conclusions and recommendations
require a word of caution. Based on the experience from a single case, the conclusions may not be
extrapolated to all intra-oral cysts. There are intra-oral

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CORRESPONDENCE

swellings of varied pathologies (e.g., hypervascular

neoplasms)2 that should not be aspirated. This and the
recommended airway management plan should not
be applied, as stated by these authors; to any huge
cystic lesion of the oral cavity irrespective of its pathology. Surgical procedures in the airway that precede
a definitive airway have the potential for converting
an anticipated difficult airway into a dangerously difficult airway.3,4 Anticipated pediatric difficult airways
also require special considerations that may have
been overlooked by these authors.5 We feel that each
case should be assessed individually, and an approach
determined on the basis of experience, equipment
availability and situation. Ultimately, the goal should
always be patient safety with the best achievable clinical outcome. We believe that; as with other scenarios,
the maxim even for airway management for oral surgery should be (literally) airway first!.
Naveen Eipe MD
Doreen Yee MD
Sunnybrook Health Sciences Centre, University of
Toronto, Toronto, Canada
E-mail: neipe@yahoo.com
Conflicts of interest and sources of support: None
declared.
Accepted for publication February 16, 2007.
References
1 Raveenthiran V, Sam CJ, Srinivasan SK. A simple
approach to airway management for a giant sublingual
dermoid cyst. Can J Anesth 2006; 53: 12656.
2 Liu DG, Ma XC, Li BM, Zhang JG. Clinical study of
preoperative angiography and embolization of hypervascular neoplasms in the oral and maxillofacial region.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2006; 101: 1029.
3 Eipe N, Pillai AD, Choudhrie A, Choudhrie R. The
tongue flap: an iatrogenic difficult airway? Anesth
Analg 2006; 102: 9713.
4 Kummer C, Netto FS, Rizoli S, Yee D. A review of traumatic airway injuries: potential implications for airway
assessment and management. Injury 2007; 38: 2733.
5 Brooks P, Ree R, Rosen D, Ansermino M. Canadian
pediatric anesthesiologists prefer inhalational anesthesia
to manage difficult airways. Can J Anesth 2005; 52:
28590.

Reply:
We thank Drs. Eipe and Yee for their interest in our
recent Letter to the Editor. They have sought clarification regarding certain details which were omitted due
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June, 2007

to space constraints in our original correspondence.

Ultrasonography done prior to needle aspiration confirmed the cystic nature of the mass. The boy cooperated
very well, and hence he did not require any form of
anesthesia for needle aspiration of the cyst. One may,
however, consider local or topical anesthesia according to
the exigency of a given case. We did transoral aspiration
as the needle had to traverse only a thin mucosa and cyst
wall by this route. For the same reason, pain was minimal during the procedure.
It is unfortunate that Drs. Eipe and Yee misconstrued our conclusion. We never recommended needle
aspiration of solid neoplastic lesions or vascular lesions.
But we would strongly recommend this approach for
benign, huge cystic lesions of the mouth. Logical extrapolation does not require a great number of cases. When the
liquid content of a dermoid cyst can be aspirated, why
would the same principle not be applicable to a lingual
cyst or cystic hygroma with a much thinner content?
We agree that oral surgical procedures have the
potential to convert a difficult airway into dangerous
airway. However, fine needle aspiration is a minimally
invasive procedure that does not carry the same implications as a surgical intervention. Sudden flooding of
airway with cystic content, as could happen with surgical
incision of a cyst, is unlikely with fine needle aspiration.
Accidental rupture of a cyst due to manipulations in an
airway first approach could be more dangerous than
a needle decompression.
Drs. Eipe and Yee are right in claiming that the
airway is of prime importance in oral surgery. But we
would modify their maxim and state make the airway
accessible first - before securing it in the context of
achieving easy and safe airway access in the setting of
large oral cysts.
Venkatachalam Raveenthiran MCh
Sam Cenita MCh
Souna K. Srinivasan MD
Rajah Muthiah Medical College, Annamalai
University, India
E-mail: vrthiran@yahoo.co.in

Endotracheal intubation through a

laryngeal mask/supraglottic airway
To the Editor:
The Laryngeal Mask AirwayTM (LMA) is an integral
device in the management of the difficult airway.1 It
can be used as a rescue ventilatory device in a cannot
intubate-cannot ventilate situation; and to provide
a conduit to insert an endotracheal tube (ETT) to

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CANADIAN JOURNAL OF ANESTHESIA

TABLE Dimensions of the lar yngeal mask air way (LMA)

and Intubating Lar yngeal Air way TM (ILA), and the largest size of cuffed endotracheal tube (ETT) which can pass
through them
Device/size

IBW

Largest ETT

LMA/ILA length*

LMA Classic/Unique
3
3050 kg
6.0 mm cuffed
22 cm
4
5070 kg
6.0 mm cuffed
22 cm
5
70100 kg
7.0 mm cuffed
23.5 cm
ILA
3.5
5070 kg
7.5 mm cuffed
18 cm
4.5
70100 kg
8.5 mm cuffed
20 cm
IBW = ideal body weight; *Distance from the external edge of the
circuit connector to the internal ventilatory opening.

attain a definitive airway. Once an LMA ClassicTM or

UniqueTM (LMA North America Inc., San Diego, CA,
USA) is in position, the insertion and maintenance
of an ETT tube may pose several logistic difficulties.
First, the size of the ETT is limited by a) the circuit
connector which cannot be removed and b) the
presence of aperture bars at the ventilatory opening
(Table, top). Second, the length of ETT is limited
by the size of the ETT which can pass through the
LMA. A 6.0-mm internal diameter ETT of 2830 cm
in length may not be long enough to be optimally
positioned in mid trachea, or allow safe removal of the
LMA over the ETT.
Turkstra and Pellerin reported a clever strategy to
insert an ETT through a size 4 LMA UniqueTM in a
patient undergoing awake craniotomy.2 By cutting off
the proximal portion of the LMA and the connector,
the limitation of the connector and inadequate ETT
length were overcome; and they were able to insert
a 6.5mm armoured ETT over a bronchoscope into
the trachea.
We wish to mention two alternative strategies to
insert an ETT in patients with a supraglottic airway device in situ. First, the Intubating Laryngeal
AirwayTM (ILA, Mercury Medical, Clearwater, FL,
USA) is a new, reusable supraglottic airway with
functionality and insertion technique similar to an
LMA.3,4 This device has a removable circuit connector, no aperture bars at the ventilatory opening, and
shorter shaft distances compared to the LMA (Table,
bottom). Compared to the LMA, the Intubating
Laryngeal AirwayTM permits the passage of larger
diameter, longer ETTs without having to sever the
suppraglottic airway shaft and connector. Our experience with the Intubating Laryngeal AirwayTM indicated that regular ETTs could be passed successfully into
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June, 2007

the trachea, with or without bronchoscopic guidance.

The Intubating Laryngeal AirwayTM may be deflated
and left in situ; or it can be removed in a fashion similar to that of the LMA-FastrachTM.
Second, an Aintree intubation catheter (Cook
Medical Inc., Bloomington, IN, USA) is a hollow ETT
exchange catheter with an internal diameter of 4.7 mm
and external diameter of 6.3 mm.5 With an LMA or
supraglottic airway in situ, an Aintree catheter loaded
on a pediatric bronchoscope can be advanced through
it under bronchoscopic guidance into the trachea. The
bronchoscope and the LMA/supraglottic airway are
removed sequentially and an ETT is then railroaded
over the Aintree catheter into the trachea.6
In unanticipated cannot intubate-cannot ventilate
situations, the priority should be the establishment of
ventilation by insertion of an LMA or other supraglottic airway. If effective ventilation cannot be attained,
then a surgical infraglottic airway should be inserted.
On the other hand, if effective ventilation is established, instead of removing the supraglottic airway
and attempting alternative intubating devices, one can
insert an ETT or Aintree catheter through the supraglottic device using one of the two strategies stated
above. Familiarity with these techniques in routine
situations would permit their usage in unanticipated
difficult airway situations.
David T. Wong MD
Glenn P. McGuire MD
Toronto Western Hospital, University of Toronto,
Toronto, Canada
E-mail: david.wong@uhn.on.ca
Accepted for publication February 23, 2007.
References
1 American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists
Task Force on Management of the Difficult Airway.
Anesthesiology 2003; 98: 126977.
2 Turkstra TP, Pellerin HG. Modification of the LMAUnique to facilitate endotracheal intubation (Letter).
Can J Anesth 2006; 53: 12667.
3 Mercury Medical, The Cookgas ILA intubating
laryngeal airway and removal stylet. Available from
URL; http://66.77.149.134/pdf_edu/EnglishILA.
pdf (accessed December 9, 2006).
4 Klein MT, Jones J. Utility of the Intubating
Laryngeal Airway: report of an observational study.
Anesthesiology 2005; 103: A846 (abstract).
5 Cook Critical Care Products. Aintree intubation cath-

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CORRESPONDENCE

eters. Available from URL; http://www.cookmedical.

com/cc/dataSheet.do?id=1314 (accessed December 9,
2006).
6 Zura A, Doyle DJ, Orlandi M. Use of the Aintree intubation catheter in a patient with an unexpected difficult
airway. Can J Anesth 2005; 52: 6469.

References

Reply:
Any Harbour in a Storm
We are honoured by the interest in our letter1 by Drs.
Wong and McGuire. Of the laryngeal mask airway
(LMA) limitations identified by Osborn,2 Turkstra,1
and Wong and McGuire, the circuit connector is the
most hindering.
Our purpose had been to inform anesthesiologists of
a novel airway technique; Wong and McGuire suggest
two other potential techniques that could be considered if a supraglottic device is present and intubation
becomes necessary. The Intubating Laryngeal Airway
(LMA North America, San Diego, CA, USA) could
have advantages over the LMA-Unique, as proffered by Wong and McGuire. However, the ILA has
only recently been approved and hospital availability is
limited compared to LMA products. The ILA was
not approved for use when the events described in our
letter took place. Hopefully the advantages proposed by
Wong and McGuire will lead to wider acceptance and
accessibility of the ILA devices. Note that the ILA
has recently been approved in a disposable form, the
air-Q.
We concur that the Aintree intubation catheter (Cook
Inc, Stouffville, ON, Canada) is an excellent option for
intubating patients who have a supra-glottic airway in
place, as previously described by several authors.3,4 The
Aintree device is easier to advance through the LMA
than an ETT, and the potential to oxygenate the patient
with the Aintree catheter should not be overlooked.
We did not describe a cannot intubate-cannot ventilate (CICV) situation, but a contaminated supraglottic airway with difficult fibre-optic laryngoscopy and
restricted access (easy ventilation). That being said, we
would add that, if ventilation through a supraglottic
airway is inadequate, leading to CICV, one should also
consider fibre-optic guided intubation,5 free-hand or
through the supra-glottic airway. If possible, it may be
quicker than a surgical option.
Any harbour in a storm is sage advice; hopefully our technique and those advanced by Wong and
McGuire can provide haven to a colleague in need.

CAN J ANESTH 54: 6

Timothy P. Turkstra MD M Eng FRCPC

Hlne G. Pellerin MD FRCPC
London Health Sciences Centre University
Hospital, University of Western Ontario, London,
Canada
E-mail: timothy.turkstra@londonhospitals.ca

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June, 2007

1 Turkstra TP, Pellerin HG. Modification of the LMAUnique to facilitate endotracheal intubation (Letter).
Can J Anesth 2006; 53: 12667.
2 Osborn IP, Soper R. Its a disposable LMA, just cut it
shorter for fiberoptic intubation, Anesth Analg 2003;
97: 299300.
3 Higgs A, Clark E, Premraj K. Low-skill fibreoptic
intubation: use of the Aintree catheter with the classic
LMA. Anaesthesia 2005; 60: 91520.
4 Cook TM, Silsby J, Simpson TP. Airway rescue in acute
upper airway obstruction using a ProSeal laryngeal
mask airway and an Aintree catheter: a review of the
ProSeal laryngeal mask airway in the management of
the difficult airway, Anaesthesia 2005; 60: 112936.
5 American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists
Task Force on Management of the Difficult Airway.
Anesthesiology 2003; 98: 126977.

The Esophageal-Tracheal Combitube

and esophageal injuries
To the Editor:
We read with interest the article of Vezina et al.
Complications associated with the EsophagealTracheal Combitube in the pre-hospital setting.1
It would be of interest to know which Combitube
sizes were used for the patients who experienced
complications. The authors collected data regarding
Combitube size, but did not report the findings.
The Combitube is available in two sizes: small
adult (SA) Combitube (37 Fr), recommended for
patients with a height between 120 to 180 cm, and
the large adult Combitube (41 Fr) for patients taller
than 180 cm, with an overlap between both sizes.2
The external diameter of the Combitube 41 Fr is
relatively large, and may constitute a potential risk for
damage to soft tissue. It has been recommended that
the SA Combitube (37 Fr) be used independent of an
upper height limit.3,4 Due to its smaller size, the SA
Combitube (37 Fr) is easier to use, and may be less
traumatic to soft tissues.

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CANADIAN JOURNAL OF ANESTHESIA

We share the authors concern regarding possible esophageal injuries, however, most reported
esophageal injuries are associated with over-inflation
of the distal balloon of the Combitube with 20 to
40 mL of air (instead of the recommended 10 mL
volume with the Combitube 37 Fr, or 12 mL with
the Combitube 41 Fr).2 We believe that strict adherence to the manufacturers guidelines regarding the
inflation of Esophageal tracheal Combitube cuffs may
prevent potentially life-threatening complications such
as esophageal injuries.
Sonia J. Vaida MD
Pennsylvania State University College of Medicine,
Hershey, USA
E-mail: svaida@psu.edu
Accepted for publication March 14, 2007.
References
1 Vezina M-C, Trepanier CA, Nicole PC, Lessard MR.
Complications associated with the Esophageal-Tracheal
Combitube in the pre-hospital setting. Can J Anesth
2007; 54: 1248.
2 Gaitini LA, Vaida SJ, Agro F. The EsophagealTracheal Combitube. Anesthesiol Clin North America
2002; 20: 893906.
3 Krafft P, Schebesta K. Alternative management techniques for the difficult airway: esophagealtracheal
Combitube. Curr Opin Anaesthesiol 2004; 17: 499
504.
4 Walz R, Davis S, Panning B. Is the Combitube a useful
emergency airway device for anesthesiologists? (Letter).
Anesth Analg 1999; 88: 233.

Reply:
We thank Dr. Saida for her interest in our manuscript,
and share her concerns regarding the possible role of
Combitube size in the genesis of reported complications. In planning our retrospective study, we chose to
document Combitube size, but unfortunately, the data
recording done by the emergency medical technicians
was incomplete for this component of the database. This
made it impossible to include Combitube size in the
analyses, and for this reason, we chose not report incomplete results. This limitation, reflecting a limitation of
the retrospective design was addressed in the discussion.
We emphasize that the EMT protocol for selection of
Combitube size was recommended by the manufacturer
(small Combitubes for patients < 180 cm in height; large
Combitube for patients >180 cm in height). We cannot
document that this protocol received strict adherence.
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We agree with Dr. Saida that the use of an oversized

Combitube may represent a risk factor for esophageal
injury, although no supporting evidence exists in the
literature. We also agree that the manufacturers recommendations regarding balloon inflation should be
strictly followed. Finally, we wish to emphasize that,
given the incidence of complications found in our study,
use of the Combitube should be limited to cardiopulmonary resuscitation situations where qualified personnel
are unavailable for tracheal intubation.
Claude A. Trpanier MD
Pierre C. Nicole MD
Martin R. Lessard MD
Hpital de lEnfant-Jsus du CHA, Qubec, Canada
E-mail: delalaitue@videotron.ca

A combined rigid videolaryngoscopyexible brescopy intubation technique

under general anesthesia
To the Editor:
One of the difficulties associated with fibreoptic intubation is to maintain the fibrescope in the median
plane while advancing its tip into the pharynx and
towards the laryngeal inlet. Rigid videolaryngoscopy has recently been described in difficult airway
management. Although videolaryngoscopy reveals
the larynx more frequently than conventional direct
laryngoscopy, it often proves difficult to advance the
endotracheal tube towards the larynx1 and through
the cords. Use of a stylet helps greatly, however this
blind stylet technique has a failure rate and risks airway trauma. Repeated attempts may increase risks of
hypoxemia, cardiovascular stress and aspiration. As an
alternative to this technique, we suggest the combined
use of flexible fibrescopy with rigid videolaryngoscopy
to utilize the strengths of both techniques.
The rigid videolaryngoscope (DCI, Karl Storz,
Tuttlingen, Germany) is a laryngoscope whose
Macintosh blade has fibreoptic bundles for illumination and transmission of the image onto an LCD
screen. In our setting, the video screens for the fibrescope and videolaryngoscope are placed side by side.
After induction of general anesthesia the anesthesiologist performing laryngoscopy introduces the videolaryngoscope until clear visualization of the upper larynx
is obtained on the screen. Then, while holding the
videolaryngoscope in place, the operator uses her/his
right hand to guide the tip of the fibrescope as closely
as possible to the glottic inlet. The second operator,
the fibrescopist, completes passage of the fibrescope

493

CORRESPONDENCE

FIGURE The rigid videolar yngoscope and the flexible

fibrescope connected to their LCD-screens.

into the trachea to a position above the carina, and

then completes tracheal intubation by railroading a
preloaded tracheal tube over the fibrescope.
After institutional approval for a pilot evaluation,
we used this technique in 16 patients after each gave
informed consent. No patient had signs predictive of
difficult intubation. All intubations were performed
after induction of general anesthesia and were successful on the first attempt. The procedure was rated
as being easy or very easy in 15 cases and fair in one,
despite the presence of a Cormack and Lehane grade
greater than 2 in five patients. Patients vital signs
remained stable throughout the procedures, and
operator satisfaction was rated as good or very good
in all cases. Postoperatively, one patient experienced a
hoarse voice, and painful swallowing was present in six
patients. No serious complications occurred.
The combination of direct laryngoscopy with flexible fibrescopy has been reported in two intensive care
patients2 and as an aid to teach fibreoptic intubation.3
In our setting, the videolaryngoscope facilitates progression of the fibrescope towards the larynx by keeping the oropharynx open and reducing erratic lateral
advancement. The fibrescopist takes advantage of the
double-screen view, allowing simultaneous vision of
the fibrescopic view of laryngeal structures and the
position of the tip of the fibrescope through the videolaryngoscope. The control of the fibrescope helps
to reach and enter the larynx and may be particularly
valuable with higher Cormack and Lehane grades.
Our technique may also reduce the force from the
laryngoscope blade exerted at the base of the tongue,
CAN J ANESTH 54: 6

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June, 2007

hence reducing the associated nociceptive stress of

intubation.4 The combined technique permits visual
control of the passage of the tube over the fibrescope
into the laryngeal inlet and may help in resolution
of difficulties at this point. Use of a fibrescope to
reach the trachea and subsequent advancement of the
endotracheal tube is always under indirect vision.
With our technique however, the procedure can be
visualized through the videolaryngoscope. This can
be considered an advantage over fibreoptic intubation
alone. One limitation is that it requires two operators.
This limitation is of modest importance, since the
management of any anticipated difficult intubation
ideally needs two operators.
A large series is required to confirm these promising results, particularly with respect to evaluating
ease of intubation, cardiovascular stress reduction and
improvement of difficult airway management.
Nicolas Greib MD*
Nathalie Stojeba MD*
W. Allister Dow MB ChB FRCA
John Henderson MB ChB FRCA
Pierre A. Diemunsch MD PhD*
CHU Hautepierre,* Strasbourg, France
Vancouver General Hospital, Vancouver, Canada
Gartnavel General Hospital, Glasgow, United
Kingdom
Institution to which this work is attributed: CHU
Hautepierre, Strasbourg, France.
E-mail: allidow@hotmail.com
No external financial support was given for this
work.
Presented in part at the 2006 ASA Annual Meeting,
October 15th, 2006 Chicago, IL, USA.
Accepted for publication February 20, 2007.
References
1 Kaplan MB, Berci G. Rigid videolaryngoscopy in the
management of the difficult airway (Letter). Can J
Anesth 2004; 51: 94.
2 Hagberg CA, Westhofen P. A two-person technique for
fibrescope-aided tracheal extubation/reintubation in
intensive care unit (ICU) patients. J Clin Anesth 2003;
15: 46770.
3 Doyle DJ, GlideScope-assisted fiberoptic intubation: a
new airway teaching method. Anesthesiology 2004;
101: 1252.
4 Khan FA, Mahboobi SK. Effect of laryngoscopy and
tracheal intubation on pulse pressure and influence of
age on this response. Anaesth Intensive Care 2004; 32:
53541.