Airway security and safety: Is it a priority in the prone position during upper endoscopic procedures under general anesthesia?

Dear Editor,

I read with interest the original article “Non-intubated general anesthesia in the prone position for advanced biliopancreatic therapeutic endoscopy: A single tertiary referral center experience”.[1] There is a need to scrutinize and analyze this study critically and interpret it appropriately. The authors stated clearly that there is the absence of a secure airway associated with limited possibility to support ventilation due to shared airways and added that the main issue remains the difficult control of the airway. They also reported that ventilatory monitoring by capnography was judged not reliable. Finally, they concluded that general anesthesia may be regarded as a safe procedure.[1] Anesthesia is a medical specialty with a reputation for the highest possible standard of safety.[2] First, do no harm![3] for our profession, this means that our most important concern must be patient safety. However, I want to highlight the following considerations: first, One of the primary concerns of induction of anesthesia in a prone position is the potential for loss of airway during induction, restriction to the proper use of supraglottic airway devices and airway maneuvers, reduced ability to manage hemodynamic instability, and the hypotension associated with induction of anesthesia in prone position due to reduction of the venous return related to compression of the inferior vena cava and decreased left ventricular compliance.[4] Second, ventilatory monitoring of end tidal carbon dioxide is essential monitoring,[5] but it was reported as not reliable[1] during the procedures which have a real mean time of 57 min. Third, interpreting the absence of failure as an indication of the absence of risk and presence of safety, although the preoperative evaluation was done by experienced anesthesiologists and the procedures were performed by skilled anesthesiologists, adverse event as desaturation happened in 35% of cases. One patient had to be turned supine for airway management, however rotation of the patient to supine requires time and support of personnel that may not be necessary immediately available, and it may interrupt the procedure during a critical stage.[6] This event (emergency supine position) happened at a ratio of 1:153, which needs to be taken critically as this ratio happened in the anesthetic course provided by skilled and dedicated anesthesiologists. Gourda[7] reported that up to 72% of adverse events (cardiac arrest) in endoscopic setting was related to airway management problems. In summary, the major advantages of this technique were saving time and patient self-positioning to avoid nerve injury may not be accepted as a trade-off for hazarders of anesthesia induction in a prone position, airway safety management, emergency need for a supine position as airway rescue maneuver and proper monitoring of ventilation through endotracheal intubation.

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