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ANESTH ANALG 1992:75:14156

LETTERS TO THE EDITOR

References 1. Greene Nh4. Anesthesiology journals, 1992. Anesth Analg 1992;74116

20. 2. Swift 1. Gulliver's travels. London: Penguin Classics, 1985223-41.

In Response:

new anesthesia journal, the "Journal of Inadequate Papers" (JIP). Perhaps we can leave the satire to Jonathan Swift. Nicholas M. Greene, MD Department of Anesthesia Yale University School of Medicine New Haven, CT 06510

Dr. Lewis presents us with a rich smorgasbord of comments, complaints, and recommendations. Those most deserving of response include: The comment to the effect that "it is surely the duty of editors to separate the wheat from the chaff' in deciding what to accept for publication is a truism. In fact, as suggested in the article Dr. Lewis is commenting upon, failure of editors to recognize this responsibility is one of the reasons why there are so many articles in today's plethora of anesthesia journals that can best be characterized as space-occupying lesions or just plain shifting dullness. The author of the article being commented upon declined to quantitate this by statistical analysis and citation of data but instead elected to make the point obliquely and subtly. Too obliquely and subtly for Dr. Lewis, perhaps, but in today's litigious society in which three times more lawyers than doctors are produced, prudence, to say nothing of civility, is in order. There are many reasons why editors are remiss in this regard, reasons we need not dwell upon in writing, but certainly they include the pressure put on some editors to publish less than memorable materials rather than adhere to standards so high that an issue of their journal might contain only 50 pages. The suggestion that authors of articles submitted for publication remain anonymous during the review process is naive. Two-thirds of the papers submitted for publication that merit publication represent a continuum of articles coming from established, productive research programs. One does not need a title page to know where they come from. If in doubt, one has only to check the references cited. The remaining third of the papers submitted for publication that warrant publication come from first-time or infrequent authors who remain functionally anonymous because few if any reviewers know them. The plea for auctorial anonymity also includes an element of offensiveness. It implies that the intellectualintegrity of reviewers is so fragile as to yield to the sin of bias simply because the name and origin of the paper under consideration are known to the reviewer. One need not impugn the honesty and objectivity of reviewers of papers as a weakness inherent in the peer-review process. Also, of course, one of the responsibilities of editors-in-chief is to monitor critiques of reviewers and to eliminate those reviewers who produce critiques vapid, hostile, or biased. Such quality control is most readily achieved by relying upon a restricted number of reviewers of demonstrable ability and proven objectivityand reliability (eg, an editorial board), rather than covering the countryside with requests for manuscript reviews from inexperienced consultants even if they happen to be expert in the topic involved. An expert is not always necessarily a good reviewer. Finally, this reader is not accustomed to being left speechless but he finds he is totally aphasic when trying to respond to the suggestion that rejected papers be published, along with reasons for rejection, in, presumably a

Another Approach With the Laryngeal Mask Airway To the Editor: I read with interest the letter by Dr. Benumof on the use of the Brain laryngeal mask airway (LMA) to facilitate fiberscopic intubation (1). I too use the LMA as a routine in the management of patients in whom it may be difficult to visualize the larynx conventionally. I resexve the technique for those patients who would not otherwise be candidates for rapid-sequence induction and cricoid pressure. I begin by a conventionalmask gaseous induction using isoflurane or halothane in oxygen. Once the patient is judged to be "deep" enough to tolerate an airway, I insert the LMA and complete the spontaneous ventilation induction. I then insert the fiberscope "loaded with a 6.0 uncuffed endotracheal tube (ETT) through the fiberscope swivel connector (Portex)and into the LMA. I introduce the scope and ETT in the manner described by Dr. Benumof, while maintaining anesthesia through the LMA. After intubation, the breathing system can then be connected to the ETT to continue anesthesia before the final step, which is to change the small ETT for another of the required diameter. For this purpose I use a gum elastic bougie (barely long enough) or a "bicycle cable," which is passed through the 6.0 ETT before the ETT and LMA are removed together. Reintubating over the bougie is facilitated by a 90" counterclockwise twist of the ETT. The advantages of this technique are that "no bridges are burned as spontaneous ventilation is maintained, anesthesia can be continued through the LMA until the moment the trachea is intubated, and an appropriate-sized ETT is used for the duration of the surgery. Unlike Dr. Benumof I retain the E l T in the trachea in cases of difficult intubation until I am satisfied that the patient is awake and protective reflexes have returned. I share Dr. Benumof's view that there is a role for the LMA in the management of a difficult intubation but would add that experience is needed with the technique and that safety may be enhanced by maintaining spontaneous ventilation until the airway is secured with an endotracheal tube. David I. Thomas, FFARCS Department of Anesthesia University of Texns Medical Branch Galveston, TX 77550

Reference I. Benumof JL. Use of the laryngeal mask airway to facilitate fiberscopeaided tracheal intubation. Anesth Analg 1992;7431-.

Another approach with the laryngeal mask airway.

156 ANESTH ANALG 1992:75:14156 LETTERS TO THE EDITOR References 1. Greene Nh4. Anesthesiology journals, 1992. Anesth Analg 1992;74116 20. 2. Swift...
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