We are intrigued by the report of Dhonneur et al.  1and would like to congratulate them for successfully intubating the trachea with an Airtraq® laryngoscope (AL; Guangzhou Intmed Medical Appliance Co., Tianhe, Guangdong, China) in two morbidly obese parturients undergoing “emergency” cesarean delivery.

Although it is an interesting case report, in our opinion, it raises issues regarding use of equipment for difficult airways in emergency cesarean delivery. The authors1seem to have had training on a manikin and to have performed the clinical learning process, and they suggest that the AL was efficient in cases of difficult intubation. It is not clear whether the clinical learning process included the use of the AL in straightforward nonobstetric cases or elective cesarean delivery or/and nonemergency difficult airway scenarios. Somehow, they managed to include the AL in their algorithm for the emergency difficult airway in obstetrics.

The only published literature for use of the AL in the difficult airway is by Maharaj et al.  2Maharaj et al.  2compared the AL's performance with that of the Macintosh laryngoscope in five simulated scenarios of difficulty of tracheal intubation on a manikin (SimMan; Laerdal, Kent, United Kingdom). Although they concluded that the AL was superior to the Macintosh laryngoscope in difficult airway scenarios, the only scenario in which the AL was superior to the Macintosh laryngoscope was the manikin with tongue edema. But even in that scenario, 2 of 25 anesthesiologists could not intubate the trachea with the AL. In our opinion, this study alone does not validate using the AL for difficult airway scenarios in obstetric emergencies.

There seems to be an urgency to conquer the management of the difficult airway in obstetric cases, but is there a danger of losing the conventional and tested skills (e.g. , use of a McCoy laryngoscope for the first case1) while rushing to find a magic bullet?

The conclusion of Dhonneur et al.  1to consider the AL as a primary airway management device for the difficult airway in emergency caesarean delivery is, in our opinion, premature and daring.

*University Hospital of Birmingham, Birmingham, United Kingdom. doc_chandan@yahoo.co.uk

Dhonneur G, Ndoko S, Amathieu R, Housseini LE, Poncelet C, Tual L: Tracheal intubation using the Airtraq® in morbid obese patients undergoing emergency cesarean delivery. Anesthesiology 2007; 106:629–30
Maharaj CH, Higgins BD, Harte BH, Laffey JG: Evaluation of intubation using the Airtraq or Macintosh laryngoscope by anaesthetists in easy and simulated difficult laryngoscopy: A manikin study. Anaesthesia 2006; 61:469–77