Principles of Airway Management, 2nd Ed (1996)

Principles of Airway Management, 2nd Ed. B. T. Finucane and A. H. Santora. St. Louis: Mosby-Year Book, 1995, ISBN 0-8151-3337-5, 344 pp, $29.95. This new edition of Principles of Airway Management (first edition previously reviewed in Anesth Analg 1989;68:548) is eagerly anticipated due to an increasing interest in airway management among anesthesiologists. This new edition, however, is clearly aimed at a broader audience including emergency physicians, internists, residents in all specialties, nurse anesthetists, nursing and medical students, and respiratory therapists. Many chapters have been revised and updated, but the book retains a convenient size (despite an increase of 57 pages), a pleasing typeface, plentiful illustrations (234), and judicious use of lists. Chapter 1, "Anatomy," now combines the basic adult information with the comparative anatomy of the pediatric airway, but with little actual change in content. Chapter 2, "Basic Life Support," has been substantially updated with the recent changes in American Heart Association guidelines with respect to airway management. A difficult problem, that of resuscitation in an age of communicable lethal diseases, is discussed, but with no resolution of the issues. It is cold comfort to read that one is more likely to contract tuberculosis than human immunodeficiency virus from respiratory droplets. The meat of airway management comes in the chapters on evaluation, indications and preparation, equipment, and techniques of intubation. These are generally good quality, with significant updating (such as the inclusion of Mallampati classification) and removal of extraneous material. For instance, one would not expect a lot of detail in this kind of text on the use of the double-lumen endotracheal tube, and this topic has in fact been removed since the first edition. A rare error in Chapter 5 is a misquoted reference, in which an unusually high fraction of mortality is attributed to airway management; in fact, the reported mortality was related to overall anesthetic management, many of the deaths being the result of respiratory depression in patients transferred directly from the operating room to inpatient wards. Some mention of the controversy over succinylcholine use in children would have been useful in the material on drugs, as would a discussion of the alternative rapidonset muscle relaxants. Fiberoptic intubation is discussed in its own chapter, perhaps placed a little early in the book before the basic material. Here are the nuts and bolts of what is now an essential technique in the management of airways in the hospital setting. The section on topical anesthesia for awake intubations was expanded and improved from the first edition. A description of the extremely valuable retrograde wire technique is given but is incomplete (don't try this at home until you've seen it done). Intubation through the laryngeal mask airway (LMA) is a useful technique, but the main difficulties (removing the LMA or securing the tube with the LMA in place) are not thoroughly discussed. The use of the fiberoptic technique in the anesthetized patient is presented with directions on the use of the Patil mask, but no mention is made of an alternative approach that permits ventilation through an endotracheal tube placed nasally. The "Difficult Airway" chapter has been substantially revised since the first edition. The message here is awareness of the difficult airway and a realization that "more of the same, only better" does not solve the problem. An excellent discussion of the ASA Difficult Airway Algorithm is presented in functional segments; however, one is not immediately certain of the procedure for the "cannot ventilate, cannot intubate" situation until a short discussion in the section on the obstetrical patient; the material is fully presented at the end of the chapter following other material. The current gold standard for management of the unstable spine is in-line traction, which is not mentioned here--nor are the merits of various alternatives presented. Yet here is the main interest of the emergency physician and the paramedic, for every intubation in the emergency room or on the street is difficult and every neck unstable, if only due to lack of time for evaluation and preparation and limited equipment. Fortunately, not much progress has been made in discovering new complications, and little has changed since the first edition. Unfortunately, discussion of aspiration remains wholly inadequate. A practitioner outside the specialty of anesthesiology might not realize the degree of anxiety provoked by the "full stomach." There are no index entries here for "full stomach," "NPO," "cricoid pressure," or "Sellick maneuver." Of course, no other recent airway text has covered this topic well, either. "Surgical Management" is improved and contains good discussions of protocols and algorithms for the percutaneous tracheostomy and the cricothyrotomy, as well as the formal tracheostomy. A nice description of the silk tie technique is given, but its role in the difficult extubation is not described. The choice of technique depends on the personal skills of the individuals assembled at the bedside. A few of these techniques may be practiced in nonemergency situations, but others must be learned on mannequins or performed on patients only in the presence of a skilled practitioner. The ultimate approach is the tracheostomy, and thus adequate preparation for a difficult intubation includes the presence of a well-trained individual, usually a surgeon. Finally, a small-print paragraph (a quotation from an unnamed source?) states that "No algorithm, protocol, technique, or maneuver … has been thoroughly evaluated … to establish its degree of efficacy." The "Pediatric Airway" chapter has been updated with a new and detailed section on resuscitation of the newborn, including appropriate flowcharts and a new Table explainingApgar scoring. The final chapter, "Mechanical Ventilation," has a distinct intensive care unit flavor. In the operating room, mechanical ventilation is common, and the concerns and techniques are similar. However, not mentioned is the nightmare of transport of the ventilator-dependent patient; how are these patients to be managed if they are dependent on large amounts of positive end-expiratory pressure, for instance? This reviewer has not seen a text of this size or with similar goals done as well and would quickly recommend it to anyone who asks, "what book should I use?" This book is not meant to be the complete airway reference but does cover the basics broadly and well and is worth the revision. Francis L. Miller, MD, PhD Department of Anesthesia Hahneman University Philadelphia, PA 19103