I applaud the attempt of Mark et al. to address the compli-
cated issue how to manage the difficult airway in Noma
patients. Admittedly, this is not an easy task to find the
safest and best way under these difficult conditions. But
we must be well aware that we deal with elective proce-
dures not with emergency situations. The points that I am
attempting to convey are:
· The approach to open the mouth by cutting the trismus
can cause some hemorrhagic problems.
We can never be sure that it doesn't bleed into the mouth
and down the trachea. Aspiration is possible, because the
mini-tracheostomy tube has no cuff. In one report about
the use of minitracheostomy in elective surgery one con-
dition was considered to be essential: The surgical proce-
dure should be non-hemorrhagic .
· It is very difficult to manually ventilate the lungs of
adult patients by using the conventional anesthesia bag
or a self inflating bag through a small tube .
· We clearly lack good information about the rise of pCo2
in manually ventilated patients through a small tube. The
manual ventilation through a small transtracheal tube was
primarily designed for the emergency treatment of the
hypoxic, difficult to intubate patient [3, 4].
· Why do the authors make only 2 attempts AT blind na-
sal intubation? There are several good, easy and success-
ful techniques of blind nasal intubation [5±8].
· The method of cricithyroid aspiration is not without oth-
er risks. Life threatening complications can occur .
How should we treat these complications in poorly equi-
ped hospitals of developing countries?
In my opinion the method of choice for difficult intubat-
ions of elective Noma children and adults under these
simple conditions remains the intubation with the fiber-
Why should we put our elective patients through an un-
1. Cases JI, Ferrandaz M (1991) Minitracheostomy in elective sur-
gery of the larynx: an alternative to formal tracheostomy. Can J
2. Benumof JL, Scheller MS (1989) The importance of transtrache-
al Jet ventilation in the management of the difficult airway. An-
3. Jacoby JJ, Harmelbury W (1956) Transtracheal resuscitation.
4. Ravussin P, Freeman J (1985) A new transtracheal catheter for
ventilation and resuscitation. Can J Anaesth 32:60±64
5. Sugiura N, Miyake T (1992) The use of a nasogastric tube as an
aid in blind nasal nasotracheal intubation. Anesthesiology
6. Sugiura N (1997) Letter. Anesthesiology 87:449
7. Gorbach MS (1987) Inflation of endotracheal tube cuff as an aid
to blind nasal endotracheal intubation. Anesthesia Analg
8. Benumof JL (1991) Management of the difficult airway with
special emphasis on awake tracheal intubation. Anesthesiology
9. Spencer CD, Beatty HN (1972) Complications of transtracheal
aspiration. N Engl J Med 286:304±305
10. Tassonyi E, Lehmann C, Montandon D (1990) Fiberoptically
guided intubation in children with gangrenous stomatitis. Anes-
P. Schüller DEAA
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