instruction in awake fibreoptic intubation using the trainees as subjects

Abstracts presented at the Difficult Airway Society Annual

Meeting in London, 22–23 November 2002

Evaluation of a model for surgical airwaytraining

S.G. Clarke and S.M. YentisMagill Dept of Anaesthesia, Intensive Care & Pain Management,

Chelsea & Westminster Hospital, London, UK

Learning and practising cricothyroidotomy and similar

procedures is an essential part of anaesthetic training, yet

trainees are not obliged to attend courses that teach them.

Furthermore, available cricothyrotomy trainers/manikins

are expensive, preventing their widespread use. Our aim

was to evaluate a simple, inexpensive ‘homemade’ model

(from plastic breathing system tubing, sticky tape, card-

board/plastic drug tray, rubber glove and swabs) for

teaching/practising surgical airway techniques.

Methods

Following Ethics Committee approval, 20 anaesthetic

trainees were recruited after informed consent. Each

completed a questionnaire detailing previous experience

in surgical airway training/procedures. They were indi-

vidually shown a demonstration of transtracheal catheter-

isation and Minitracheotomy on the model, and allowed

to practise them themselves. Participants evaluated aspects

of the model according to their prior experience, from 1

(strongly disagree) to 5 (strongly agree).

Results

Six SHOs and 14 SpRs (five year 1–2; nine year 3–5)

participated; 12 had not attended a training course. Median

(IQR [range]) number of procedures performed on mod-

els/manikins were 1.5 (0 – 2 [0 – >5]) for cricothyroid

puncture; 1 (0 – 2.5 [0 – >5]) for Minitracheotomy; and 0

(0 – 1 [0 – >5]) for percutaneous tracheostomy; cor-

responding values for procedures on patients were 0 (0 –

0 [0 – >5]), 0 (0 – 2 [0 – >5]) and 4 (0 – >5 [0 – >5])

respectively. Evaluation scores are shown in the Table.

Discussion

We have been using the model in our regular Simulator

Centre courses for the past two years, and the above

results confirm our impression of its usefulness.

Adequate success rates in cricothyrotomy requires regu-

lar practice [1]. This easily constructed model provides a

cheap alternative for regular practise and teaching.

Acknowledgements

Dr S. Bajenov & Dr R. Morris, Sydney Medical

Simulation Centre, Australia, provided the original idea

for the model.

Reference

1 Prabhu AJ, Wong DT, Correa RK, Lanzieri M, Imasogie N,

Chung F. Training improves cricithyroidotomy success rate, DAS

Annual Meeting; Oxford, 2001.

A national survey of the use of bite guardsand critical incidents involving the laryngealmask airway

J.P. Blackburn, A. Con and C. MooreDept of Anaesthetics, Moorfields Eye Hospital, City Road, London, UK

A critical incident at our hospital involving a patient

biting through the stem of a flexible laryngeal mask

airway prompted a literature search showing one similar

critical incident [1]. The prevalence and incidence of

laryngeal mask airway obstruction or damage by a patient

Instructions to Authors and rules for publication of abstracts presented at specialist society meetings may be found in the general Instructions to Authors

in the Jan issue of Anaesthesia or on the journal’s website (http://www.blackwellpublishing.com/journals/ana/submiss.htm).

Table 1 Evaluation scores for the training model. Values aremedian (IQR [range]).

<5 surgical airway proceduresd model appears a reasonable substitute

for practice4 (4–5 [2–5])

d I am more comfortable with the equipmenthaving used this

4 (4–5 [4–5])

d I would be more confident now, if I hadto perform this on a patient

4 (4–5 [2–5])

>5 surgical airway proceduresd model reasonably resembles the real thing 3.5 (3–4 [2–5])d model would be useful training aid

for inexperienced trainees5 (4–5 [4–5])

d trainees should use this model before‘practising’ on patients

5 (4–5 [4–5])

d I would use this model for teachingsurgical airways

5 (4–5 [4–5])

Anaesthesia, 2003, 58, pages 506–512.....................................................................................................................................................................................................................

506 � 2003 Blackwell Publishing Ltd

and the use of bite guards to prevent this was investigated

in Great Britain & Ireland.

Methods

A postal questionnaire was sent to one teaching hospital

and one district general hospital in each of the 12 health

regions in Great Britain & Ireland. Five specialist centres

were also contacted. All anaesthetists of were asked to

complete a questionnaire regarding the use of flexible and

rigid laryngeal mask airways and the use of bite guards

with these devices. A second questionnaire was also sent

to the nurse in charge of recovery at each hospital, asking

about the observed use of bite guards and the incidence of

airway obstruction and damage to laryngeal mask airways

in the recovery area.

Results

Of 451 anaesthetists contacted, 42% responded; 60.5%

were consultants, 25.5% SpRs, 7.3% SHOs and 6.7%

other grades. Sixty-three percent of consultants, 45% of

SpRs, 38% of SHOs, 58% of other anaesthetists and 43%

of recovery staff never used a bite guard in conjunction

with a laryngeal mask airway of any sort. A bite guard was

routinely used by 4% of consultants, 3% of SpRs, 18% of

SHOs, 20% of other anaesthetists and 12% of recovery

staff. Biting of a laryngeal mask airway by a patient,

resulting in airway obstruction, had been experienced by

18 users of the flexible laryngeal mask airway (7.3%) and

71 users of the standard laryngeal mask airway (18.8%).

The recovery staff reported an average of two incidents

per month of laryngeal mask airway obstruction.

Discussion

We are not aware of any recent survey of this kind. The

use of a bite guard with a laryngeal mask airway is an

uncommon practice. However, the occurrence of airway

obstruction with the laryngeal mask airway is high.

Further investigation may be useful in eliciting the true

national incidence of such critical events.

Reference

1 Quinlan J. Reinforced laryngeal mask severed by biting.

Anaesthesia 2000; 55: 186.

Ventilation of a model lung through variouscricothyrotomy devices

R.M. Craven and R.G. VannerAnaesthetic Dept, Gloucester Royal Hospital, Gloucester, UK

Oxygenation via emergency tracheal access is required

when the patient is no longer breathing, tracheal

intubation fails and a facemask or other airway such as a

laryngeal mask cannot ventilate the patient’s lungs. The

incidence of this occurring after induction of general

anaesthesia is in the order of 1:10000 cases [1] and this is

therefore a rare event for any one anaesthetist. Various

devices have been marketed for emergency transtracheal

oxygenation [2]. There is little evidence, however, for the

relative effectiveness of these different devices, especially

in situations ranging from no upper airway obstruction to

complete upper airway obstruction.

Methods

In this study we developed a model lung, comparable to

commercially available models [3], which we used to test

the effectiveness of ventilation using three commercially

available cricothyrotomy cannulae and surgical cricothyro-

tomy over a range of upper airway resistances. A 13-G

Ravussin cannula (VBM Medical), a 4-mm Quicktrach

(VBM medical), a 6-mm Melker (Cook) and a cuffed

6-mm tracheal tube were used in turn to ventilate the

model lung through a cricothyrotomy. We defined

adequate ventilation of the lung as achieving a minute

volume of 7 l.min)1.

Results

The 6-mm cuffed tracheal tube provided consistent good

ventilation independent of upper airway resistance. Of

the other three devices, the Ravussin with jet ventilation

and the Melker with a standard anaesthetic circuit

performed best. The Ravussin cannula with jet ventila-

tion provided excellent ventilation with a patent upper

airway, but with complete upper airway obstruction

ventilation was impossible. The Melker device provided

good ventilation with moderate to complete airway

obstruction, but at low upper airway resistances provided

a reasonable but suboptimal minute volume of 5 l.min)1.

The 4-mm Quicktrach provided poor ventilation unless

the airway was occluded.

Discussion

Overall it would seem from these results that the 6-mm

Melker device provides at least reasonable and at best very

good ventilation, whatever the patency of the upper

airway, in comparison to the Ravussin cannula in which a

proportion of patients will be unable to be ventilated.

Combined with its easier insertion with fewer complica-

tions compared to a surgical cricothyrotomy, and the

ability to use it with a standard anaesthetic circuit, we feel

Anaesthesia, 2003, 58, pages 506–512......................................................................................................................................................................................................................

� 2003 Blackwell Publishing Ltd 507

this makes the 6-mm Melker the technique of choice for

emergency transtracheal ventilation.

References

1 Benumof JL, Scheller MS. The importance of transtracheal

jet ventilation in the management of the difficult airway.

Anesthesiology 1989; 71: 769–78.

2 Vanner R. Emergency cricothyroidotomy. Current Anaesthe-

sia and Critical Care 2001; 12: 238–43.

3 Righini ER, Marangoni E, Volta CA, Alvisi R, Bortolazzi S,

Gritti G. Inspiratory resistance imposed by the laryngeal

mask airway: in vitro versus in vivo comparison. Anaesthesia

1997; 52: 872–8.

Randomised comparison of the laryngealtube and the laryngeal mask during anaesthesiawith controlled ventilation

T.M. Cook,1 B. McCormick1 and T. Asai2

1 Anaesthetic Dept, Royal United Hospital, Combe Park, Bath, UK

2 Anaesthetic Dept, Kansai Medical University, Moriguchi City,

Osaka 570-8507, Japan

The laryngeal tube has been evaluated for brief periods of

anaesthesia only [1, 2]. The device has been modified

since its introduction. This evaluation compares the new

laryngeal tube with the classic laryngeal mask airway

throughout anaesthesia with controlled ventilation.

Methods

Seventy-two ASA 1-2 patients were studied. Anaesthesia

was with total intravenous anaesthesia using propofol,

fentanyl and rocuronium. Patients were randomised to

airway management with the laryngeal tube or laryngeal

mask airway. Manufacturer’s instructions were followed

for all aspects of airway use.

Results

Insertion was successful with 36/36 laryngeal mask

airways and 35/36 laryngeal tubes. Insertion of the

laryngeal tube required more manipulations than the

laryngeal mask airway (p < 0.05), although the time

taken was identical. Complications were infrequent.

Airway seal pressure was 28 cm H2O with the laryngeal

tube and 20 cm H2O with the laryngeal mask airway

(p < 0.05). The peak airway pressure to deliver 7 ml.kg)1

was 3 cm H2O higher with the laryngeal tube than the

laryngeal mask airway (p < 0.05). Ventilation was perfect

with the laryngeal tube in 32/35 cases and with the

laryngeal mask airway in 29/32 (p > 0.05). Gas leak

around the laryngeal mask airway occurred more

frequently with the laryngeal mask airway than the

laryngeal tube. There were more manipulations required

in the laryngeal tube group during maintenance of

anaesthesia. The airways were equally well tolerated

during emergence and recovery and complications were

equal in each group. Postoperative sequelae were similar

in incidence, severity and number of patients affected

with either device.

Discussion

The laryngeal tube allows an improved airway seal for

lung ventilation compared to the laryngeal mask airway.

However it requires a greater number of airway manip-

ulations for insertion. Ventilation via the laryngeal tube

requires a higher peak pressure than with the laryngeal

mask airway.

References

1 Asai T, Murao K, Shingu K. Efficacy of the laryngeal tube

during intermittent positive pressure ventilation. Anaesthesia

2000; 55: 1099–102.

2 Dorge V, Ocker H, Wenzel V, Schmucker P. The laryngeal

tube: a new simple airway device. Anesthesia and Analgesia

2000; 90: 1220–2.

Plasma lidocaine levels during local anaesthesiaof the airway

K. Williams, G. Barker, R. Harwood and N. WoodallDepartment of Anaesthesia, Norfolk and Norwich University NHS

Trust, Norfolk, UK

We report a combined technique of direct application,

nebulisation and spray-as-you-go local anaesthesia for

airway endoscopy and intubation. Topical lidocaine in

a dose of 9 mg.kg)1 appears to be safe for fibreoptic

bronchoscopy [1]; however, when nebulised, most of the

drug is lost [2]. This study assesses the acceptability of this

combined method of airway anaesthesia and measures the

plasma lidocaine concentrations achieved in 18 subjects

attending a training course.

Methods

Local Research and Ethics Committee approval was

obtained and informed consent given by all delegates

volunteering for the study. Following 3 lg.kg)1 intraven-

ous glycopyrronium and xylometazoline 0.1% intranasally,

200 mg lidocaine 4% was nebulised. Lidocaine 5% and 10%

was sprayed into the nose and oropharynx respectively.

Further doses of lidocaine 4% were administered to the



larynx via a fibrescope. A nasotracheal tube was passed once

the vocal cords were unreactive. Lidocaine administration

was limited to 9 mg.kg)1. For the purpose of dose

calculation we estimated that less than 25% of the nebulised

lidocaine reached its site of action [2]. Therefore only

50 mg of the 200 mg nebulised was included in our

calculation of the dose administered. Heart rate, non-

invasive blood pressure and oxygen saturation were

recorded automatically at 5-min intervals. After a baseline

blood sample, further samples were taken at 10-min

intervals until 60 min after the last dose of local anaesthetic.

These were assayed for lidocaine using high performance

liquid chromatography with UV detection. Delegates

graded levels of anxiety, pain and coughing using written

and visual analogue scales; in addition, subjects recorded

any local anaesthetic side-effects they experienced.

Results

We studied 18 volunteers. In all cases, conditions for

fibreoptic endoscopy and intubation were good. Eleven

subjects received the maximum calculated lidocaine dose

of 9 mg.kg)1. The average dose used was 8.7 mg.kg)1.

All plasma lidocaine concentrations assayed were below

the toxic level of 5 mg.l)1 [3]. Three volunteers reported

feeling light-headed following the procedure, despite

normal blood pressures. Of these, two had the highest

plasma lidocaine concentrations recorded in this study:

3.5 and 4.5 mg.l)1. Sixteen of the 18 subjects found

endoscopy and intubation acceptable, two found it

enjoyable and no subject rated it as distressing.

Discussion

This method of airway anaesthesia was acceptable to this

small group of unsedated subjects. It produced good

conditions for fibreoptic intubation. A maximum calcu-

lated lidocaine dose of 9 mg.kg)1 failed to produce toxic

plasma concentrations of lidocaine in a series of 18

subjects. Those with highest blood levels experienced

useful warning symptoms.

References

1 Efthimou, J, Higenbottom, T, Holt D, Cochrane GM.

Plasma concentrations of lignocaine during fibreoptic

bronchoscopy. Thorax 1982; 37: 68–71.

2 Clay MM, Clarke SW. Wastage of drug from nebulisers: a

review. Journal of the Royal Society of Medicine 1987; 80: 38–9.

3 Foldes FF, Molloy R, McNall PG, Koukal LR. Comparison

of toxicity of intravenously given local anesthetic agents in

man. Journal of the American Medical Association 1960; 172:

1493–5.

A realistic manikin for airway training

J.P.H. Fee,1 J.M. Murray,1 A. McBride2 and T. Edgar2

1 Department of Anaesthesia and Intensive Care and 2 Northern

Ireland Technology Centre, Queen’s University of Belfast, Belfast, UK

Basic and advanced airway training is an essential

component of the education of health professionals.

Existing airway training devices lack anatomical and

functional realism. This paper outlines the development

of an improved airway trainer for use in medical and

nursing education. The project involved a team of

medical educationalists, clinicians, materials scientists,

structural engineers and medical physics technicians.

Methods

Anatomically accurate data describing the upper airway

were obtained from a spiral CT scan of a male patient.

Using the 2-mm thick enhanced scan, the skin, bones,

cartilage, trachea and bronchi were automatically delin-

eated by combining thresholding, mathematical mor-

phology, and distance maps. A reference 3-D Computer

Aided Design (CAD) model was immersed in the image

and automatically deformed to the airway contours. The

intensities of parenchyma, vessels, and lesions were

estimated by means of automatic Gaussian fitting on the

imaging histogram. This first result was then refined by

topological and geometrical analysis which provided

automatic delineation of anatomical structures. Following

this, stereolithography was used to ‘rapid prototype’ a

3-D object from the 3-D CAD file. A stereolithography

machine then used a computer-controlled laser to cure a

photosensitive resin, layer by layer, to create the 3-D part

(the result is a tangible 3-D object, or physical model,

made from the CAD drawing by directing ultraviolet laser

radiation on to a vat of polymer resin (liquid plastic))

After curing in an ultraviolet oven, each piece was then

hand-polished and finished to specifications.

Results

Five first articles were produced (Figure 1). A video clip

of a fibreoptic bronchoscopy using the prototype will be

presented.

Discussion

This study describes the methodology used to create the

automatic segmentation of the head, neck and internal

airway with delineation of important anatomical and

functional structures from a routine CT scan. Using the

methods proposed in this study, we have developed and



confirmed the accuracy and usefulness of a 3-D airway

model suitable for further development as an airway

training device.

Acknowledgments

The project was supported by Queen’s University

Medical Devices Centre (QUMED) in collaboration

with Medical Educational Technologies Inc., Sarasota,

FL, USA.

Instruction in awake fibreoptic intubationusing the trainees as subjects

N.M. Woodall, G.L. Barker and R.J. HarwoodDepartment of Anaesthesia, Norfolk and Norwich University NHS

Trust, Norfolk, UK

We report our experience of 12 training courses

using course delegates as subjects for training in awake

intubation [1].

Methods

Delegates attended either as participants or observers.

Airway local anaesthesia, fibreoptic endoscopy and

tracheal intubation were performed on participants by

other course members. Adverse events during airway

anaesthesia and endoscopy were recorded. Additional data

were collected from application forms. All delegates

completed an anonymous questionnaire: participants

were asked to grade sensations such as anxiety, pain,

coughing and gagging on a 5-point scale.

Results

Eighty-nine delegates presented for training; 47 had

previously performed 10 or fewer fibreoptic intubations

and eight had performed none before. Of the 89

delegates, 21 were observers. Endoscopy of the airway

was performed to the level of the trachea in all 68

participants; nasotracheal intubation was completed in 59.

Gagging was rated as slightly uncomfortable by 36 (53%)

of the 68 participants; eight (12%) found this uncomfort-

able and one rated this as very uncomfortable. Twenty-

three (34%) reported no discomfort associated with

gagging during endoscopy or intubation. Thirty-three

subjects (48%) found the procedure slightly painful and

36 (53%) reported anxiety associated with the procedure.

No delegates rated the sensation of endoscopy or

intubation as distressing. Overall, the procedure was rated

as acceptable by 57 (84%) subjects and enjoyable by

11 (16%). Severe paraesthesia of the hands developed in

one individual. Minor nasal bleeding occurred in two

cases, and did not interfere with endoscopy. One delegate

felt faint following endoscopy; this settled with rest and

intravenous fluid. One delegate vomited an undigested

meal following endoscopy despite not having eaten for

8 h. Six hours after endoscopy, one delegate developed a

fever with rigors; he was treated with antibiotics and

suffered no long term effects.

Discussion

The use of course delegates as subjects for training in

airway endoscopy was acceptable to this self-selected

group of anaesthetists when conducted under closely

controlled conditions.

Reference

1 Patil V, Barker G, Harwood R, Woodall N. Training course

in local anaesthesia of the airway and fibreoptic intubation

using course delegates as subjects. British Journal of Anaesthesia

2002; 89: 586–93.

Comparison of the fibreoptic ’scope and plasticbougie for tracheal intubation in simulateddifficult laryngoscopy

A.G. Marfin,1 K.C. Hames,1 J.J. Pandit,1 M.T. Popat1

and S.M. Yentis2

1 Nuffield Department of Anaesthetics, The John Radcliffe Hospital,

Oxford, UK 2 Magill Department of Anaesthesia, Chelsea and

Westminster Hospital, London, UK

The gum elastic bougie is the most common aid used to

facilitate intubation during Cormack and Lehane grade-3

laryngoscopy [1]. The bougie technique is blind and

multiple attempts may traumatise the airway. Flexible

fibreoptic endoscopy offers a continuous view and may

minimise the need for multiple attempts. We aimed to

Figure 1



compare the performance of the fibreoptic ’scope and the

single-use bougie for orotracheal intubation in patients

with two different simulated grade-3 laryngoscopic views.

Methods

With Local Research Ethics Committee approval and

after obtaining written informed consent, 64 ASA 1 and

2 adult patients undergoing day-case dental procedures

were studied. Simulation of laryngoscopy grade-3 was

achieved by lowering the Macintosh laryngoscope blade

so the epiglottis descended, hiding the vocal cords. In

32 patients, a grade-3a view was simulated (epiglottis only

just obscuring the view of the arytenoids). In 32 patients,

a grade-3b view was simulated (epiglottis touching the

posterior pharyngeal wall). Once the simulated view was

established, one operator maintained the laryngoscope in

position while another confirmed the simulated grade and

commenced intubation. Patients were randomised to

intubation using either the fibreoptic ’scope or the

bougie. If the intubation failed with the first device, after

a period of adequate re-oxygenation, the alternative study

device was used. Success rates and intubation times were

recorded in both simulation groups. Statistical comparison

was with the v2 or t-tests, with p < 0.05 taken as

statistically significant.

Results

Grade-3a view: All 16 fibreoptic-guided intubations were

successful compared with eight of 16 (50%) in which a

bougie was used (p < 0.02). In the eight patients in

whom the bougie had failed as the primary method,

successful intubation was achieved in all cases using the

fibreoptic scope.

Grade-3b view: In eight of 16 cases (50%), fibreoptic-

guided intubation resulted in tracheal placement of the

tube compared with one out of 16 cases (6%) using the

bougie (p < 0.02). Where the bougie had failed as the

original method, intubation was successful with fibreoptic

’scope in 10 of 15 cases (67%); where the fibreoptic ’scope

was unsuccessful initially, intubation was achieved using

the bougie in only one of 8 cases (13%) (p < 0.04). In all

successful intubations using either technique, the total

intubating times were within 120 s and there were no

significant differences between the times using either

device.

Discussion

In simulated grade-3a laryngoscopy, the fibreoptic ’scope is

very much more successful than the bougie as a device for

tracheal intubation. The same dramatic degree of success

could not be demonstrated in a grade-3b laryngoscopy,

although the results we obtained with the fibreoptic ’scope

were significantly different to those with the bougie. The

results have at least two important clinical implications:

(a) the bougie may not be the device of choice in the setting

of an unexpected grade-3 laryngoscopy; (b) a patient with

a known, previously recorded grade-3 laryngoscopy might

reasonably be considered a sufficiently ‘difficult’ candidate

for an awake intubation technique.

Reference

1 Latto IP. Management of difficult intubation. In: Latto IP,

Vaughan RS, Eds. Difficulties in Tracheal Intubation. London:

W.B. Saunders, 1997; 107–60.

Comparison of the single-use plastic bougieand the multiple-use gum elastic bougie fortracheal intubation in simulated grade-3difficult laryngoscopy

A.G. Marfin, K.C. Hames, J.J. Pandit and M.T. PopatNuffield Department of Anaesthetics, The John Radcliffe Hospital,

Oxford, UK

The gum elastic bougie is the most common aid used to

facilitate intubation duringgrade-3 laryngoscopy. Tradi-

tionally in the United Kingdom, the multiple-use gum

elastic bougie has been used [1], which is washed (but not

sterilised) between uses. With increasing concern regard-

ing multiple-use devices and cross-infection, a new

single-use plastic bougie has been introduced. Anecdo-

tally, it appears that any bougie which lacks flexibility and

curvature, is more difficult to use [2]. The purpose of this

study was to compare success rates for tracheal intubation

in simulated Cormack and Lehane Grade-3 laryngoscopy.

Methods

With Local Research Ethics Committee approval and

after obtaining written informed consent, we studied

32 ASA 1 and 2 adult patients (day-case dental proce-

dures). Simulation of grade-3a laryngeal views (epiglottis

only just obscuring the view of the arytenoids) was

achieved by lowering the Macintosh laryngoscope blade

[3]. One operator maintained the laryngoscope in posi-

tion while another commenced intubation. Patients were

randomised to either the single-use plastic bougie or

multiple-use gum elastic bougie. If the intubation failed

with the first device (one attempt only), the alternative

study device was used. Success rates and intubation times

were recorded. Statistical comparison was with the v2 or

t-tests, with p < 0.05 taken as statistically significant.



Results

The multiple-use bougie was successful in 15/16 cases;

the single-use bougie in only 9/16 cases (p < 0.041). Of

the seven cases which failed with the single-use bougie,

the multiple-use bougie was successful in five. The single-

use bougie was successful in the single case in which the

multiple-use bougie failed. Total intubating times were

under 85 s in all cases, and there were no significant

differences between the groups.

Discussion

The difference in success rates between the multiple-use

and single-use bougies is striking. Although minimising

the risk of cross-infection is important, it is of concern

that the newly introduced device performs less well and

introduces the more important risk of failed intubation. It

is not possible to blind a study such as this, and it would

be very important for others to repeat our findings, to

minimise the risk of bias. A rational approach would be to

suggest that, where a bougie is to be used routinely, the

single-use plastic bougie may be used; where it is used to

facilitate an urgent intubation, the multiple-use gum

elastic type should be used. Alternatively, in the latter

instance, a fibreoptic scope may also be used.

References

1 Nolan JP, Wilson ME. An evaluation of the gum elastic

bougie. Intubation times and incidence of sore throat.

Anaesthesia 1992; 47: 878–81.

2 Surendra Kumar D, Jones G. Is your bougie helping or

hindering you? Anaesthesia 2001; 56: 1121.

3 Cook TM. A new practical classification of laryngeal view.

Anaesthesia 2000; 55: 274–9.



instruction in awake fibreoptic intubation using the trainees as subjects

Documents