Previous article Table of Contents  Next article

Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 74-75

Anticipated difficult airway: Planning, safety and ethics while applying a novel technique

1 Department of Critical Care Medicine, Jupiter Hospital, Thane, Maharashtra, India
2 Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC) Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Amol T Kothekar
Professor, Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain, 2nd Floor, Main Building, Tata Memorial Centre, Mumbai - 400 012, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.SJA_669_20

Rights and Permissions
Date of Submission22-Jun-2020
Date of Acceptance22-Jun-2020
Date of Web Publication5-Jan-2021

How to cite this article:
Narkhede AM, Kothekar AT. Anticipated difficult airway: Planning, safety and ethics while applying a novel technique. Saudi J Anaesth 2021;15:74-5

How to cite this URL:
Narkhede AM, Kothekar AT. Anticipated difficult airway: Planning, safety and ethics while applying a novel technique. Saudi J Anaesth [serial online] 2021 [cited 2022 Aug 19];15:74-5. Available from:


We were intrigued by the successful management of an anticipated difficult airway in a patient with severe cervical spine pathology by Koyama et al.[1] using fluoroscopy guided technique. We congratulate the authors for their novel outlook and successful execution of endotracheal intubation in a patient with difficult airway.

We would like to raise a few concerns regarding the above stated novel technique. Firstly, we could not identify the author's back up plans in case of failure of the primary plan. All current airway management guidelines stress on meticulous planning for a difficult airway including backup plans commonly known as plan B and C.[2],[3] It would be prudent to have these plans handy especially when the primary plan is novel and not commonly used. Secondly, authors have shown use of lateral fluoroscopic view showing sagittal section of the airway which can easily differentiate trachea from oesophagus. When the sagittal view is not accompanied by a simultaneous frontal view in coronal plane, it is difficult to avoid the potential risk of the bougie going laterally leading to trauma and disastrous bleeding.

Radiologic-Assisted Endotracheal Intubation by Reier et al.[4] was done in an awake patient. Safety margin is high in an awake patient since the patient can take care of own airway. Subjecting sedated patient to such uncommon methods involves greater risk especially when safer alternatives are available.

It may be prudent to use this novel technique in simulations, models or non-difficult airway cases before using it in a difficult airway case. Similarly, it may be ethically appropriate to use an established technique in a difficult airway situation rather than subjecting the patient to the uncertainty of a novel technique.

As authors mention the insertion of LMA, we would be interested in knowing if the authors considered using established alternatives like fibreoptic bronchoscopy through supraglottic airway device using Aintree intubation catheter or simply an intubating LMA. Wong et al.[5] in their review have described various techniques of achieving endotracheal intubation through supraglottic airway devices. A modified version of Intubating LMA known as LMA C trach also can be used in such a situation.

In conclusion, we appreciate the author's novel technique for management of a difficult airway scenario, but at the same time reassert the importance of planning, patient safety, understanding limitations of novel techniques and ethics while using these novel techniques.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Koyama Y, Tsuzaki K, Ohmori K, Ono K, Suzuki T. C-arm fluoroscopy for tracheal intubation in a patient with severe cervical spine pathology. Saudi J Anaesth 2020;14:390.  Back to cited text no. 1
  [Full text]  
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaes?th 2016;60:885-9.  Back to cited text no. 2
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel AA, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827-48.  Back to cited text no. 3
Reier CE, ReierAR. Radiologic-assisted endotracheal intubation. Anesth Analg 2004;98:1496-8.  Back to cited text no. 4
Wong DT, Yang JJ, Mak HY, Jagannathan N. Use of intubation introducers through a supraglottic airway to facilitate tracheal intubation: A brief review. Can J Anesth 2012;59:704-15.  Back to cited text no. 5


Previous article    Next article
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  IN THIS Article

 Article Access Statistics
    PDF Downloaded106    
    Comments [Add]    

Recommend this journal