Intubation of a patient lying supine on the ground

Correspondence INTUBATION OF A PATIENTLYING SUPINE ON THE GROUND To the Editor:--The optimal position of the rescuer for intubation of the patient lying on the ground has only recently received attention. 1-4As one paper was written by our group, 2 we would like to comment on Adnet et al. 1 The left lateral decubitus (LLD) position of the rescuer proposed by Adnet et al had, to our knowledge, not yet been evaluated. In our study, we included prone (recommended by the European Resuscitation Council),5 kneeling,6 sitting,7 and straddling. 3,a Here, the kneeling position fared much better (intubation time 9.6 -+ 4.1 sec) and was not significantly different from prone (8.9 -+ 2.9 sec). However, as prone is different to LLD, it is possible that LLD is advantageous in terms of intubation time and glottic exposure. We encountered several problems, however, with the prone position that might apply to the LLD position, also. First, as mentioned by Adnet et al, positions in which the rescuer is lying down are unlikely to succeed in small bedrooms. Here the kneeling and the straddling positions are superior. Second, positions in which the rescuer is lying down may be uncomfortable and even dangerous to the rescuer on contaminated surfaces. Third, the intubation time, which measures introduction of the tube only, should be seen as part of a total time that includes the positioning time from an otherwise useful or typical position. In our study, the kneeling position was assumed about 1 second faster than the prone position. Finally, the advantage of the prone and LLD positions of placing the left elbow firmly on the ground applies to rescuers above a certain height only. Smaller rescuers are not able to do so. With the prone position the critical height of the rescuer appeared to be about 170 cm. It would be interesting to know the height distribution of the participants in the study ofAdnet et al. KATt~IARINAP. KOETTER,MD

Neurological Intensive Care Unit Leopoldina-Hospital Schweinfurt, Germany TATJANAHILKER HARALDV. GENZW/2rRKER

St. John's Ambulance Mannheim, Germany MARTINALENZ, MD WOLFGANGH. MALECK

Anesthesiology Klinikum Ludwigshafen Ludwigshafen, Germany

6. Lotz P, Ahnefeld FW, Hirlinger WK: Systematisch intubieren lernen. Eckental, Atelier Flad, 1984, p 48 7. Abrams T: Tube 'em in the streets. J Emerg Med Serv 1995;20(4): 30-40 8. Koetter KP, Maleck WH: Reference for ice-pick position for intubation. Prehosp Emerg Care 1997;1:297

The authors reply:--We appreciate the comments of Koetter et al regarding the current attention paid to optimal position of the rescuer for intubation of the patient lying on the ground. While small bedrooms and hallways do pose an impediment to operator position, we maintain that the left lateral decubitus (LLD) position is almost always possible. 1 If space limitations prevent assuming a 90 ° angle to the patient, a less acute angle (even lying parallel to the patient) will allow the LLD position to be employed. In fact it is evident that when the operator's head moves closer to the ground, the tracheal axis of the patient and the visual axis of the operator are better aligned; thus, glottic visualization and intubation are facilitated. The kneeling (or straddling) position does not allow ideal alignment. Clearly, glottic visualization is improved by the LLD position. Concerning contaminated surfaces, if true danger to the rescuer is anticipated, the patient should be extricated by protected personnel before intubation. If the "contamination" is more of an "inconvenience" (eg, oil or grease on the pavement), a rescue blanket may be placed for the rescuer to lie on during the procedure. When glottic exposure is poor (more likely with the kneeling position), the incidence of intubation difficulty is increased and the possibility of complications (esophageal intubation, multiple attempts, trauma complications, failure) is greater. 2,3 The intubation time difference between the lying position and the kneeling position in Koetter's study was only 1 second, which seems to us insignificant.4 The LLD position is very comfortable, more comfortable than the prone position. In the prone position, it is more difficult to place the left elbow firmly on the ground. We did not investigate the height distribution in our study, but the smallest physician was 162 cm tall. In the case of very small rescuers, it is possible to grip the laryngoscope closer to the blade. Finally, we believe that an important benefit is afforded to the patient when the rescuer is in the LLD position: the superiority of glottic visualization. We agree that the various proposed positions should be submitted to a randomized study. We hope that this interesting reflection will motivate future investigations concerning optimal methods for intubating patients lying on the ground. FREDERICADNET, MD, PHD STEPm~NW. BORRON,MD, MS

Service d'Aide Mddicale Urgente Bobigny, France

References 1. Adnet F, Lapostolle F, Borron SW, et ai: Optimization of glottic exposure during intubation of a patient lying supine on the ground. Am J Emerg Med 1997;15:555-557 2. Koetter KP, Hilker T, Genzwuerker HV, et al: A randomized comparison of rescuer positions for intubation on the ground. Prehosp Emerg Care 1997;1:96-99 3. Guertner I, Kanz KG, Lackner C, et al: Inverse Intubation beim Polytrauma: Indikation, Technik, Erfahrungen. Intensivmedizin 1993; 30:426-427 4. Schreiber J, Graf S: Die inverse Intubation als alternative Technik zu r endotrachealen Intubation. Rettungsdienst 1997;20:10161020 5. Baskett PJF, Bossaert L, Carli P, et al: Guidelines for the advanced management of the airway and ventilation during resuscitation. Resuscitation 1996;31:201-230

References 1. Adnet F, Lapostolle F, Borron SW, et al: Optimization of glottic exposure during intubation of a patient lying supine on the ground. Am J Emerg Med 1997;15:555-557 2. Benumof JL: Management of the difficult adult airway. Anesthesiology 1991;75:1087-1110 3. Hirsch IA, Reagan JO, Sullivan N: Complications of direct laryngoscopy: A prospective analysis. Anesthesiol Rev 1990;17: 34-40 4. Koetter KP, Hilker T, Genzwuerker HV, et al: Randomized comparison of rescuer positions for intubation on the ground. Prehosp Emerg Care 1997;1:96-99 435