Comment on: Efficacy of intubation performed by trainees on patients in the lateral position

Dear Sir,

I read with great interest Goh et al’s paper on the efficacy of intubation in the lateral position.(1) I would like to congratulate the authors on their interesting paper. In their conclusion, the authors stated that intubation of patients in unconventional positions using routine airway equipment should be included in airway training for trainees, and I agree. However, I would suggest including modern equipment such as videolaryngoscopes (VLs) in this training. Our experience with VLs in the lateral position is promising.

We used several devices in patients to be intubated in the lateral position: the King Vision (Ambu, Holland), Airtraq (Prodol, Spain) and McGRATH MAC (Medtronic, USA) VLs (Fig. 1). The visualisation of the entrance to the larynx was evaluated on the POGO (percentage of glottic opening) scale, and the first-pass-success endotracheal intubation ratio and time of intubation were evaluated and recorded in the patient’s history. The POGO was 100% in all cases. The success ratio was 100% in all cases. Time to intubation was less than 30 seconds in every case, with no difference between VLs. There were no complications of intubation. The time to intubation is better than that reported by Goh et al when using a standard Macintosh blade laryngoscope (MCL).(1)

Fig. 1

Photographs show intubation in a patient positioned in the lateral position using the (a) Airtraq; (b) King Vision; and (c) McGRATH MAC videolaryngoscopes.

There is a limited number of papers in the literature on the use of VLs in patients in the lateral position. In one randomised trial comparing the C-MAC VL and the standard MCL, Bhat et al revealed that use of VL allows for faster intubation in the lateral position.(2) There was no difference in success ratio between the C-MAC VL and MCL. In another report from Takenaka et al, the Airway Scope (AWS) VL provided significantly better intubation conditions compared to the MCL.(3) Tracheal intubation was successful during the first attempt with the AWS in all patients and with the MCL in 85.3% of patients. Time of intubation was also significantly shorter in the AWS group compared to MCL. The AWS also significantly reduced the intubation difficulty scale score compared with the MCL. Komatsu et al compared the use of the AWS in two lateral positions (left and right) and found no significant difference.(4) However, there is no comparison of different VLs in this setting.

In conclusion, based on our results and literature review, different VLs can be successfully used for intubation patients positioned in the lateral position.