Reduction of pain on injection of propofol: a comparison of fentanyl with remifentanil.

We read with interest the randomized clinical trial by Joo et al. (1) of difficult airway management, in which they compared the merits of inserting the intubating laryngeal mask airway (ILMA) under general anesthesia with awake fiberoptic intubation (AFOI). Joo et al. (1) rightly point out that the ILMA can be used as the sole airway without tracheal intubation. Because a clear airway had been already obtained in patients in the ILMA group, it would be interesting to know why they required tracheal intubation. Having excluded patients at risk for aspiration of gastric contents, difficult ventilation, and supraglottic abnormalities, what indications, apart from the procedures, existed for tracheal intubation? The supraglottic laryngeal mask airways (LMA-Classic (2,3), ILMA or Fastrach (4), and the LMA-ProSeal (5)) all permit positive pressure ventilation or spontaneous ventilation with minimal morbidity provided the appropriate size is used and the device is correctly placed. Even abdominal procedures, for which tracheal intubation was formerly considered mandatory, can be managed with supraglottic devices. The role of supraglottic airway devices for “nonconventional” uses is now acknowledged by reference texts within the specialty (6). Joo et al.’s study (1) challenges the “gold standard” of AFOI in a selected group of patients with previous or predicted difficult laryngoscopy. Perhaps the next “gold standard” to be challenged is whether every patient with a difficult airway requires endotracheal intubation. The advent of supraglottic airways, and the unique attributes of each, justifies subjecting airway strategies to randomized clinical trials (7). Thus procedures like AFOI, which require expensive equipment and consume valuable operating theater time and are “adamantly refused” by some patients, may have their indications better defined.