912
Correspondence
bronchoscope. The Shiley tube is transparent for most of its length and it is possible with a fibreoptic bronchoscope to visualise clearly through the plastic the surface of the upper airway. Unfortunately the cuff of this tube is only translucent and hence it is not possible without disturbing the position of the tube to see whether the cuff is inducing physical changes in the tracheal epithelium. Although in the case reported above periodic fibre-optic bronchoscopy was not used to determine how long to leave the endotracheal tube in position it is suggested that this approach could help. Since tracheostomy is not without hazard periodic fibre-optic bronchoscopy through a transparent endotracheal tube to inspect
regularly the whole of the upper airway in contact with the tube could only lead to an improvement in patient care by removing the guess work as to when or even if the patient should have a tracheostomy. Perhaps manufacturers could be persuaded to make endotracheal tubes totally transparent. Sundsvall Sjirkhus, 851 86 Sundsvall, Sweden. University Department of Anaesthetics, Birmingham.
JON GJESSING
P.J. TOMLIN
An attack on tracheostomy Tracheal intubation cannot be avoided in prolonged mechanical ventilation for the intensive care patient, but is it not time the pendulum swung away from tracheostomy in these cases, except for special situations? Whilst both the laryngeal and direct tracheal routes have their own advantages and disadvantages, and certainly neither is ideal, the avoidance of unnecessary infection is surely a paramount goal in the gravely ill, and it has rightly led to the current trend towards non-invasive techniques. Bacterial contamination of the tracheostomy wound is almost unavoidable, and whilst this does not necessarily lead to infection, there is always the risk of this, and the sicker the patient the greater the danger. Normally harmless organisms may be lethal in such patients. The soggy lungs of the adult respiratory distress syndrome are a perfect medium for such bacteria and we know that the grave lesions and mortality of this condition are aggravated by sepsis.'-3 Improvements in cuff design may have reduced the risk of lung infection from inhalation of infected material or secretions4 but the risk remains, and it is aggravated by tracheost~my.~.~ Whilst the specific complications of prolonged endotracheal intubation cannot be ignored, the price of avoiding them by tracheostomy may therefore be too high in the gravely ill. Moreover children and babies, with far smaller airways, are satisfactorily managed without tracheostomy in many centres, in one remarkable case for over three years.' Tracheostomy has another major hazard, namely, the risk of haemorrhage, besides the aggravated risk of later stenosis. How many deaths can be directly attributed to endotracheal intubation, and how lethal is cord ulceration ? Does the admittedly easier tracheal toilet with a tracheostomy certainly reduce the net incidence and gravity of pulmonary complications, including sepsis, despite the above evidence? Can we really be sure that tracheostomy, despite its major disadvantages, has more to offer, or
a t least is no more harmful to the sick ventilator patient than endotracheal intubation? T o adapt a currently popular expression, I suggest that on present evidence such a patient needs a hole in his neck like he needs a hole in the head-only when there is also extensive injury to these areas! Whilst the role of high frequency positive pressure ventilation (HFPPV) in the intensive care patient has yet to be fully explored,* it seems possible that its use in combination with very narrow endotracheal tubes might eventually lead to a technique of management which greatly reduces cord damage and the need for tracheostomy. National Heart Hospital, Westmoreland Street, London W I M BBA.
ALANGILSTON
References I . WALKER,L. & EISEMAN, B. (1975) The changing
pattern of post-traumatic respiratory distress syndrome. Annals of Surgery, 181, 693. 2. COLLINS, JA. (1977) The acute respiratory distress syndrome. Adcances in Surgery, 11, 171. 3 . WILSON, R.F.& SIBBALD, W.J. (1976)Acute respiratory failure. Critical Care Medicine, 4, 79. 4. SPRAY,S.D.,ZUIDEMA, G.D. &CAMERON, J.L.(1976) Aspiration pneumonia: incidence of aspiration with endotracheal tubes. American Journal of Surgery, 131, 700. 5. EL NAGGAR, M.,SADAGOPAN, S. e t a l . (1976)Factors influencing choice between tracheostomy and prolonged nasolaryngeal intubation in acute respiratory failure: a prospective study. Anaesthesia and Analgesia: Current Researches, 55, 195. 6. POLK,H.C. (1975)Quantitative tracheal cultures in surgical patients requiring mechanical ventilatory assistance. Surgery, 18, 455. 7. ZELT,B.A.&LOSSASO, A.M. (1972)Prolonged nastrotracheal intubation and mechanical ventilation in the management of asphyxiating thoracic dystrophy: a
Correspondence case report. Anesthesia and Analgesia: Current Researches, 51, 342. 8. CARLON, G.C., KLAIN,M. et a/. (1979) High fre-
913
quency positive pressure ventilation: applications in acute respiratory failure. Critical Care Medicine, 7 , 128.
Association of Dental Anaesthetists Sqfe practice ?
The Secretary-Treasurer replies
It is with the utmost regret that I must use your correspondence section to record and publish my concern at the views made public at the meeting of the Association of Dental Anaesthetists on 5 May 1979 at Scarborough. This body was formed by interested specialist anaesthetists after an informal meeting at the Association of Anaesthetists’ Annual Meeting in 1976 and one of its principle ‘motives’ was to encourage thinking and safety in dental anaesthetic techniques. I was therefore most disappointed to hear invited speakers present papers which can only put safety in dental outpatient anaesthesia back 15 or 20 years. The first speaker recommended the use of the 45” position in the dental chair using innuendo but no facts to support this view and the view that the supine position has more dangers than the erect. The second speaker regretted the obsolescence of the demand flow machines such as the Walton V because it made it more difficult to give 100% nitrous oxide-a technique which he found very useful ! The penultimate speaker then described a technique for ‘Advanced outpatient dental conservation’ in which he recounted how his patients have over 2 hr of dental treatment whilst breathing spontaneously a mixture of halothane, nitrous oxide and oxygen. Does a group of specialists, who all avow an interest in safety and progress in dental anaesthesia, really wish to disseminate views such as these? Furthermore, what made this meeting more embarrassing, was that it was held jointly with the local division of the British Dental Association and was therefore well attended by local dental practitioners. How can we hope to prevent some of the questionable practices that still occur in dental surgery anaesthesia if the putative definitive body on dental anaesthesia allows its name to be attached to practises such as these.
I am grateful to the Editor for the opportunity to comment on Dr Ward’s letter, but must make it clear that, although Secretary-Treasurer of the .Association of Dental Anaesthetists (ADA), the following views are my own and do not necessarily reflect those of the members as a whole, for their opinion has not been canvassed; it may well be expressed at one of our own meetings. Whilst I would concur with Dr Ward in condemning some of the recommendations made by the speakers at the recent meeting of ADA in Scarborough, (and support them against him in others), this seems to me only to show that differences of opinion still exist about many points of technique. When more ‘facts’ become available agreement may be greater. The ADA, whose stated aims are, ‘to further the art and science of anaesthesia for dentistry’ hopes to encourage the elucidation of such questions by provision of ‘a forum for discussion of pertinent matters by its members’. When lectures are given to those not in a position to analyse teaching critically, it may be proper only to retail universally accepted safe practice, but the ADA is composed essentially of experienced enthusiasts. Indeed Dr Ward’s letter is itself evidence that they take their branch of the art seriously. In such company unusual, even wrong-headed, views may justifiably be propounded, for the audience may be expected to recognise errors and to decide for itself what to reject. Today’s heresy may become tomorrow’s dogma and out of favour again the day after. Without freedom to express such views advance may be restrained. Let a thousand flowers bloom; quot homines, tot sen:entiae. Departnient of Anaesthesia, Manchester Royal Infirmary, Manchester MI3 9 WL.
T.M. YOUNG
Nufield Department of Anaesthetics, The Radcliffe Infirmary, MICHAEL E. WARD Oxford O X2 6HE.
Anaesthesia and homocystinuria Homocystinurea is a genetic disorder resulting from the deficiency of enzyme cystathionine synthetase and is transmitted through an autosomal recessive trait. The affected children usually manifest increased tendency to thromboembolic episodes leading to
early death. Such a complication is often precipitated by anaesthetic and surgical trauma.’ Presented here is a case of the successful management of such a child. A 7-year-old male child who had bilateral dilated
Correspondence
bronchoscope. The Shiley tube is transparent for most of its length and it is possible with a fibreoptic bronchoscope to visualise clearly through the plastic the surface of the upper airway. Unfortunately the cuff of this tube is only translucent and hence it is not possible without disturbing the position of the tube to see whether the cuff is inducing physical changes in the tracheal epithelium. Although in the case reported above periodic fibre-optic bronchoscopy was not used to determine how long to leave the endotracheal tube in position it is suggested that this approach could help. Since tracheostomy is not without hazard periodic fibre-optic bronchoscopy through a transparent endotracheal tube to inspect
regularly the whole of the upper airway in contact with the tube could only lead to an improvement in patient care by removing the guess work as to when or even if the patient should have a tracheostomy. Perhaps manufacturers could be persuaded to make endotracheal tubes totally transparent. Sundsvall Sjirkhus, 851 86 Sundsvall, Sweden. University Department of Anaesthetics, Birmingham.
JON GJESSING
P.J. TOMLIN
An attack on tracheostomy Tracheal intubation cannot be avoided in prolonged mechanical ventilation for the intensive care patient, but is it not time the pendulum swung away from tracheostomy in these cases, except for special situations? Whilst both the laryngeal and direct tracheal routes have their own advantages and disadvantages, and certainly neither is ideal, the avoidance of unnecessary infection is surely a paramount goal in the gravely ill, and it has rightly led to the current trend towards non-invasive techniques. Bacterial contamination of the tracheostomy wound is almost unavoidable, and whilst this does not necessarily lead to infection, there is always the risk of this, and the sicker the patient the greater the danger. Normally harmless organisms may be lethal in such patients. The soggy lungs of the adult respiratory distress syndrome are a perfect medium for such bacteria and we know that the grave lesions and mortality of this condition are aggravated by sepsis.'-3 Improvements in cuff design may have reduced the risk of lung infection from inhalation of infected material or secretions4 but the risk remains, and it is aggravated by tracheost~my.~.~ Whilst the specific complications of prolonged endotracheal intubation cannot be ignored, the price of avoiding them by tracheostomy may therefore be too high in the gravely ill. Moreover children and babies, with far smaller airways, are satisfactorily managed without tracheostomy in many centres, in one remarkable case for over three years.' Tracheostomy has another major hazard, namely, the risk of haemorrhage, besides the aggravated risk of later stenosis. How many deaths can be directly attributed to endotracheal intubation, and how lethal is cord ulceration ? Does the admittedly easier tracheal toilet with a tracheostomy certainly reduce the net incidence and gravity of pulmonary complications, including sepsis, despite the above evidence? Can we really be sure that tracheostomy, despite its major disadvantages, has more to offer, or
a t least is no more harmful to the sick ventilator patient than endotracheal intubation? T o adapt a currently popular expression, I suggest that on present evidence such a patient needs a hole in his neck like he needs a hole in the head-only when there is also extensive injury to these areas! Whilst the role of high frequency positive pressure ventilation (HFPPV) in the intensive care patient has yet to be fully explored,* it seems possible that its use in combination with very narrow endotracheal tubes might eventually lead to a technique of management which greatly reduces cord damage and the need for tracheostomy. National Heart Hospital, Westmoreland Street, London W I M BBA.
ALANGILSTON
References I . WALKER,L. & EISEMAN, B. (1975) The changing
pattern of post-traumatic respiratory distress syndrome. Annals of Surgery, 181, 693. 2. COLLINS, JA. (1977) The acute respiratory distress syndrome. Adcances in Surgery, 11, 171. 3 . WILSON, R.F.& SIBBALD, W.J. (1976)Acute respiratory failure. Critical Care Medicine, 4, 79. 4. SPRAY,S.D.,ZUIDEMA, G.D. &CAMERON, J.L.(1976) Aspiration pneumonia: incidence of aspiration with endotracheal tubes. American Journal of Surgery, 131, 700. 5. EL NAGGAR, M.,SADAGOPAN, S. e t a l . (1976)Factors influencing choice between tracheostomy and prolonged nasolaryngeal intubation in acute respiratory failure: a prospective study. Anaesthesia and Analgesia: Current Researches, 55, 195. 6. POLK,H.C. (1975)Quantitative tracheal cultures in surgical patients requiring mechanical ventilatory assistance. Surgery, 18, 455. 7. ZELT,B.A.&LOSSASO, A.M. (1972)Prolonged nastrotracheal intubation and mechanical ventilation in the management of asphyxiating thoracic dystrophy: a
Correspondence case report. Anesthesia and Analgesia: Current Researches, 51, 342. 8. CARLON, G.C., KLAIN,M. et a/. (1979) High fre-
913
quency positive pressure ventilation: applications in acute respiratory failure. Critical Care Medicine, 7 , 128.
Association of Dental Anaesthetists Sqfe practice ?
The Secretary-Treasurer replies
It is with the utmost regret that I must use your correspondence section to record and publish my concern at the views made public at the meeting of the Association of Dental Anaesthetists on 5 May 1979 at Scarborough. This body was formed by interested specialist anaesthetists after an informal meeting at the Association of Anaesthetists’ Annual Meeting in 1976 and one of its principle ‘motives’ was to encourage thinking and safety in dental anaesthetic techniques. I was therefore most disappointed to hear invited speakers present papers which can only put safety in dental outpatient anaesthesia back 15 or 20 years. The first speaker recommended the use of the 45” position in the dental chair using innuendo but no facts to support this view and the view that the supine position has more dangers than the erect. The second speaker regretted the obsolescence of the demand flow machines such as the Walton V because it made it more difficult to give 100% nitrous oxide-a technique which he found very useful ! The penultimate speaker then described a technique for ‘Advanced outpatient dental conservation’ in which he recounted how his patients have over 2 hr of dental treatment whilst breathing spontaneously a mixture of halothane, nitrous oxide and oxygen. Does a group of specialists, who all avow an interest in safety and progress in dental anaesthesia, really wish to disseminate views such as these? Furthermore, what made this meeting more embarrassing, was that it was held jointly with the local division of the British Dental Association and was therefore well attended by local dental practitioners. How can we hope to prevent some of the questionable practices that still occur in dental surgery anaesthesia if the putative definitive body on dental anaesthesia allows its name to be attached to practises such as these.
I am grateful to the Editor for the opportunity to comment on Dr Ward’s letter, but must make it clear that, although Secretary-Treasurer of the .Association of Dental Anaesthetists (ADA), the following views are my own and do not necessarily reflect those of the members as a whole, for their opinion has not been canvassed; it may well be expressed at one of our own meetings. Whilst I would concur with Dr Ward in condemning some of the recommendations made by the speakers at the recent meeting of ADA in Scarborough, (and support them against him in others), this seems to me only to show that differences of opinion still exist about many points of technique. When more ‘facts’ become available agreement may be greater. The ADA, whose stated aims are, ‘to further the art and science of anaesthesia for dentistry’ hopes to encourage the elucidation of such questions by provision of ‘a forum for discussion of pertinent matters by its members’. When lectures are given to those not in a position to analyse teaching critically, it may be proper only to retail universally accepted safe practice, but the ADA is composed essentially of experienced enthusiasts. Indeed Dr Ward’s letter is itself evidence that they take their branch of the art seriously. In such company unusual, even wrong-headed, views may justifiably be propounded, for the audience may be expected to recognise errors and to decide for itself what to reject. Today’s heresy may become tomorrow’s dogma and out of favour again the day after. Without freedom to express such views advance may be restrained. Let a thousand flowers bloom; quot homines, tot sen:entiae. Departnient of Anaesthesia, Manchester Royal Infirmary, Manchester MI3 9 WL.
T.M. YOUNG
Nufield Department of Anaesthetics, The Radcliffe Infirmary, MICHAEL E. WARD Oxford O X2 6HE.
Anaesthesia and homocystinuria Homocystinurea is a genetic disorder resulting from the deficiency of enzyme cystathionine synthetase and is transmitted through an autosomal recessive trait. The affected children usually manifest increased tendency to thromboembolic episodes leading to
early death. Such a complication is often precipitated by anaesthetic and surgical trauma.’ Presented here is a case of the successful management of such a child. A 7-year-old male child who had bilateral dilated
