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Wed Apr 5 18:38:03 BST 2006

As a wayward Yankee ER doc, I've been enlightened by the LMA discussion. Haven't used one, but I know they're used in the OR for short cases, dificult intubations, etc. But, they can't be considered definitive (do not secure the airway against aspiration). In my training at Detroit Receiving Hospital (ca 1980's) almost all of the trauma patients requiring intubation in the ED received nasotracheal tubes (NTI). Archaic, eh? But, we were good at it, and rarely was NTI unsuccessful in the spontaneously breathing patient (ketamine being an excellent agent to facilitate the procedure, and use a 6.5 - 7.5 cuffed tube). Even in the apneic pt, NTI can be quite successful and fairly easy to perform - with experience. I still use NTI in dificult airways, and "rescued" one apneic fellow with no neck just the other day (the intensivists groan, because of risk of sinusitis). Another technique is digital - by placing your 2nd and 3rd fingers in the hypopharynx volar side up, I have also been able to guide the tube into the glottis (I would not use this if they are awake!). These two techniques, if practiced, seem to me to be reasonable options for prehospital personnel in whose patients direct laryngoscopy and intubation are difficult. What say the anesthetists? DB

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