By: 6 January 2016
Letters to the editor

Letters to the editor

Want to comment on anything you’ve read in this issue of Journal of Anaesthesia Practice, or what’s going on elsewhere in the world of anaesthesia? Send your letters to the editor to us at

Room two needs an epidural please

Dear Editor,

Often when doing on-call duties in maternity as an obstetric anaesthetist, you will get a call from a midwife saying “Room two needs an epidural please!” Even worse is when you are fast bleeped to emergency theatre for a crash section/category-1 LSCS.

As anaesthetist, you then have to take on the challenging role of knowing the patient and conducting a safe anaesthetic – but also being quick enough to have a safe outcome for both mother and baby. This obviously cannot be achieved easily as the patient is already stressed or very anxious and the team is busy getting scrubbed.

A simple and clear handover from the midwife who has been looking after the patient for a few hours would make a great difference to the outcome of the whole preoperative phase of the mother and baby.

This can be achieved without much stress or without increasing the workload of the midwife by creating a small M2A (midwife to anaesthetist) communication card with a few important pieces of information to be handed over to the anaesthetist or communicated to the anaesthetist. The midwife could fill in this card as soon as they admit the patient and complete as things progress.

I would like to suggest that the M2A communication card includes the information shown in the example provided (see below).

letter table

I would be interested to know the views of other readers and whether this could be implemented nationally to improve patient safety.

Yours sincerely,

Avinash Aswath

Royal Bournemouth Hospital




The paediatric fibreoptic bronchoscope – a ‘humble bougie’?

Dear Editor,

An editorial by Rai in Anaesthesia describes the ‘humble bougie’ as the most widely used device to overcome a difficult intubation, and, furthermore, its use with videolaryngoscopy is responsible for improved successful intubations and reduced intubation times [1].

Paediatric difficult airway guidelines relate to the management of the unanticipated difficult airway in children aged one to eight years, and are aimed at the non-specialist anaesthetist [2].

With the above in mind, we wish to add an interesting case, whereby the ‘humble bougie’ was in fact used as a fibreoptic scope.

A prematurely born neonate, that was term (age corrected) at the time of surgery, weighing 2.9kg, was scheduled for coarctation of the aorta repair. He presented with Pierre-Robin syndrome, with a cleft palate and severe micrognathia. Plan of anaesthesia was an inhalational induction with oxygen and sevoflurane, plus muscle relaxation once adequate mask ventilation was confirmed. All essential equipment for difficult airway management was ready in light of the anticipated difficult airway. Direct laryngoscopy revealed a Cormack lehane grade 4 view. Ensuring adequate ventilation between intubation attempts, a GlideScope was used (enabling us to ‘look around the corner’) and we were able to successfully visualise the cords on screen; however, difficulty in intubating the trachea with a bougie to enable railroading of an endotracheal tube was experienced due to the flimsy nature of paediatric bougies. A paediatric fibreoptic bronchoscope was used orally as a bougie (requiring a second anaesthetist), and this provided the rigidity needed, with the extra feature of a moveable/flexible tip to aid intubation of the trachea, while visualising the process on the GlideScope screen – providing a wide-angled view. An endotracheal tube was successfully railroaded over the fibreoptic scope, confirmed by capnography.

As the editorial by Rai discusses lower success rates with single-use bougies compared with the original gum-elastic bougie in adults [1], an alternative has been demonstrated in our paediatric case.

Ethics approval to commence safety and efficacy studies on this technique has been obtained, and is currently under study.

Yours sincerely,

  1. Black, R. Newton, K.B. Ong and L. Hepburn

Great Ormond Street Hospital, London, UK



Rai, M.R. (2014) The humble bougie… forty years and still counting? Anaesthesia 69, 199–203

The Difficult Airway Society. Paediatric difficult airway guidelines (accessed 21 March 2015)


When in doubt take it out (‘But what if it is an awake fibreoptic intubation?)

Dear Editor,

The old dictum with endotracheal intubation is to take the tube out when in doubt that it is not in right position, which doesn’t seem to have changed in spite of there being numerous advanced gadgets to facilitate intubation.

Capnography [1–5], however, has been very useful in confirming endotracheal placement of tube with reportedly high sensitivity (20–100 per cent) and specificity (97–100 per cent), hence a positive predictive value of nearly 100 per cent (probability of correct endotracheal intubation if CO2 detected) and negative predictive value (probability of oesophageal intubation if no CO2 detected) of 20–100 per cent.

We would like to report this interesting incident following an awake fibreoptic endotracheal intubation.

A 74-year-old gentleman with oral malignancy and with previous radiotherapy for the same presented for an elective procedure of jaw stretch. Since he had very limited mouth opening, an awake fibreoptic intubation was performed successfully using remifentanyl sedation. Tube placement was confirmed by fibreoptic bronchoscope.

Once intubated, the tube was connected to breathing circuit with spontaneous breaths and a good capnographic trace was observed. The patient was given full intravenous anaesthetic drugs and positive pressure ventilation was attempted.

After a few breaths, we lost the capnography trace and there was a different feel while bagging. We also noted that chest movements were not adequate and air entry was limited in both lung fields on auscultation. The haemodynamics, including oxygen saturations, were maintained during this time. A quick check of the breathing system, capnography and anaesthesia machine took place. There was no kinking of the endotracheal tube, as it was a reinforced ETT.

At this point we questioned whether to take the tube out, but this was a case of difficult intubation with very distorted anatomy and requiring awake fibreoptic intubation.

Hence, without wasting much time and while the patient maintained saturations of 98–99 per cent, we quickly had another look with a fibreoptic bronchoscope. A large mucus plug was found in the trachea (causing airway obstruction); this was sucked out and the problem was resolved.

We would like to share with other readers the possibility of a mucus plug causing complete airway obstruction almost mimicking an oesophageal intubation. Similar case reports [6] have been published but in the paediatric age group.

Yours sincerely,

Avinash Aswath and Corinna Matt

Luton and Dunstable Hospital




Grmec, S. (2002) Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Med. 28, 701–704

Anton, W.R., Gordon, R.W., Jordan, T.M., et al. (19991) A disposable end-tidal CO2 detector to verify endotracheal intubation. Ann. Emerg. Med. 20, 271–275

Bhende, M.S., Thompson, A.E., Cook, D.R. & Saville, A.L. (1992) Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube placement in infants and children. Ann. Emerg. Med. 21, 142–145

MacLeod, B.A., Heller, M.B., Gerard, J., et al. (1991) Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection. Ann. Emerg. Med. 20, 267–270

Ornato, J.P., Shipley, J.B., Racht, E.M., (1992) Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device. Ann. Emerg. Med. 21, 518–523

Xue, F.-S, Luo, M.-P., Liao, X., et al. (2009) Delayed endotracheal tube obstruction by mucus plug in a child. Chin. Med. J. 122(7), 870–872