CORRESPONDENCE: LETTERS

When a process is out of control 12 February 2015

Sir, The correspondence from Raja et al.1 on iatrogenic lesions during Glidescope (GLS) intubation is extremely interesting. We would like to add some comments, as it touches important issues concerning the use of GLS, crucial also for anaesthetists. The statements on the ease of use of videolaryngoscopes and their steep learning curves that can be found in studies of comparison can lead, unfortunately, to the described iatrogenic lesions.2 The seven injuries reported occurred at the alarming rate of every 2 months in a 19-month period, after which they disappeared. Although it is not possible to determine the actual incidence (total number of intubations unknown), it is an unacceptable rate and the GLS intubation could be considered a technique to abandon. Such a high rate indicates that the process of intubation with GLS videolaryngoscopy was out of control and the complications represent a special cause and not a random variability. The special cause, as assumed by Raja, could only be related to errors in the technique of GLS intubation because of the lack of expertise with the device. The demonstration is that in almost all cases, multiple attempts of intubation have been made and in two cases, patients were easily re-intubated with direct laryngoscopy. The lack of expertise is also underlined when the Author declares that the multiple intubation attempts had involved the anaesthesia team and not a single operator, meaning that the whole staff was still in training. The absence of lesions after January 2012 confirms this suspicion. We recently published a paper in which the expertise of intubation (not only with time or success rate as indicators) with the GLS and how the expertise develops over time has been defined for the first time.3

The achievement of the 90% probability of performing an optimal intubation occurred between 70 and 80 intubations with a supervising team in which the GLS had been used routinely since 2005. Our results demonstrate that the ease of intubation with the GLS and other videos is only apparent, and this is why a number of adverse events have been reported even by skilled practitioners of airway management. Raja’s correspondence should therefore be an important stimulus to reconsider the actual advantages of the GLS videolaryngoscope as a function of an established and maintained expertise, as in many other surgical disciplines where globalisation of expertise and training has already taken place. Conflict of interest

None to declare. Caldiroli, D. & Orena, E.F. Department of Neuroanaesthesia and Intensive Care, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy E-mail: [email protected]

References 1 Raja J., Clyne S., Levine J. et al. (2014) Otorhinolaryngology management of seven patients with iatrogenic penetrating injuries from GlideScopeâ: our experience. Clin. Otolaryngol. 39, 251–254 2 Behringer E.C., Cooper R.M., Luney S. et al. (2012) The introduction of new technologies in clinical practice requires more refined technique. Eur. J. Anaesthesiol. 29, 158–159 3 Cortellazzi P., Caldiroli D., Byrne A. et al. (2014) Defining and developing expertise in tracheal intubation using a GlideScopeâ for anaesthetists with expertise in Macintosh direct laryngoscopy: an in-vivo longitudinal study. Anaesthesia 2015; 70(3), 290–295

Alternatives to Benzalkonium Chloride containing nasal preparations 20 February 2015

Sir, The prescribing of topical nasal treatment in the form of sprays and drops is common in a rhinology clinic and general 400

ENT practice. Not uncommonly do we observe that a patient reports no benefit, nasal irritation or worsening of nasal congestion after the use of a steroid nasal spray. Where there © 2015 John Wiley & Sons Ltd  Clinical Otolaryngology 40, 400–402

Correspondence

401

Table 1. Nasal drugs with and without benzalkonium chloride (BKC)

BKC containing

Non-BKC containing

Sprays

Drops

Nasules

Corticosteroids Beconase, Syntaris, Flixonase, Nasofan, Avamys, Nasonex, Nasacort Steroid and Antihistamine Dymista Cromoglycate Rynacrom, Vividrin Ipratropium Bromide Rinatec Antihistamines Rhinolast Corticosteroids Rhinocort Aqua Sympathomimetics Otrivine

Corticosteroids Betnesol, Vistamethasone Steroid and Antibiotic Betnesol-N

Nil

Sympathomimetics Ephedrine, Otrivine

Corticosteroids Flixonase

is no benefit, one has to revisit the diagnosis but also consider if the anti-inflammatory effect of the steroid is being nullified by the preservatives of the spray. These preservatives can also cause nasal irritation and make the nasal congestion worse. One of the most widely used preservatives is benzalkonium chloride (BKC) which is a quaternary ammonium compound used to prevent bacterial contamination and to preserve pharmacological activity in topical aqueous drops and sprays.1 BKC has been associated with sinonasal mucosal injury, nasal squamous metaplasia, ciliary dysmotility, genotoxicity and other untoward side effects such as nasal irritation.2 Indeed, there is also reporting of an anaphylactic reaction to nasal drops containing BKC.3 It is difficult to determine the exact incidence of sensitivity to BKC containing preparations from the available literature. However, the problem is important enough for researchers to be looking for alternatives to BKC as a preservative. One such study was a recent double-blind, randomised, placebo-controlled trial comparing preservative-free acidified nasal spray to BKC containing spray. It showed preservative-free spray to be as effective and well tolerated. The purpose of this correspondence is to update the readers on the currently available topical nasal preparations in the UK that contain BKC and the alternatives that are available should sensitivity to this

© 2015 John Wiley & Sons Ltd  Clinical Otolaryngology 40, 400–402

preservative is suspected. Table 1 shows topical nasal preparations with and without BKC. From Table 1, it can be seen the vast majority (>70%) of available topical nasal treatment contains BKC and the choice for alternatives is rather limited, but importantly it is available and awareness of this is useful for a practising rhinologist. Conflict of interest

None to declare. Qureshi, A.A. & Nilssen, E. Queen Alexandra Hospital, Portsmouth, UK E-mail: [email protected]

References 1 Graf P. (2001) Benzalkonium chloride as a preservative in nasal solutions: re-examining the data. Respir. Med. 95, 728–733 2 Ryan W.R. & Hwang P. (2010) Safety of a preservative-free acidified saline nasal spray. Arch. Otolaryngol. Head Neck Surg. 136, 1099–1103 3 Mezger E., Wendler O. & Mayr S. (2012) Anaphylactic reaction following administration of nasal drops containing benzalkonium chloride. Head Face Med. 8, 29

Alternatives to Benzalkonium Chloride containing nasal preparations.

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