Reply to “Stridor in adult patients presenting from the community: An alarming clinical sign” (Journal of the Intensive Care Society 2015, Vol. 16(3) 272–273)

We read with interest the letter on “Stridor in adult patients presenting from the community”¹ and applaud the authors for their highlighting of this important topic and the key concerns.

The authors outline two options for the management of a potentially impending airway obstruction. We would agree that tracheostomy under local anaesthesia is a good option in an anticipated difficult airway. However, we would caution that the alternative suggested of inhalational induction, whilst historically used, has been highlighted by the NAP 4² study as being particularly hazardous and was associated with a series of adverse outcomes. The rationale for its use was that a patient will awaken, whilst maintaining their airway, if intubation proves difficult. In practice, a patient with an obstructed airway will no longer be able to clear the inhalational agent, leading to a desaturating patient requiring emergency rapid intervention to prevent catastrophe. These concerns are highlighted in a recent review of the management of the obstructed airway by Patel and Pearce³ which we would direct the interested reader to.

We would suggest that despite the authors’ reservations, awake fibreoptic techniques do have a useful and important role. A crucial part of the management in this scenario is to have a back-up plan if your “plan A” fails.⁴ An awake fibreoptic technique can be used to examine the vocal cords prior to intubation, and gives the practitioner the chance to convert to an awake surgical approach if the concerns the authors highlight are encountered. Awake fibreoptic intubation was also the technique most favoured in an expert review on the management of airway obstruction due to a retrosternal mass.⁵

In situations where awake techniques are not feasible due to patient factors, we feel it is useful to consider the use of high flow nasal oxygenation with warmed, humidified oxygen to prolong the apnoea time⁶ in this patient group. We have also found this technique useful during awake fibreoptic intubation.