- Email: [email protected]
Smoking and statistical overkill
58
Universal Childhood Immunisation: is it sustainable? SIR,-One year after the official declaration of Universal Childhood Immunisation (UCI), there is a need to assess the sustainability of the success of the WHO Expanded Programme on Immunisation (EPI). The goal of UCI by the year 1990 was adopted at the World Health Assembly in 1977. On Oct 8, 1991, it was declared that the goal had been reached: official reports showed that 80% of the world’s infants had been vaccinated.l Since 1990, however, coverage has fallen in many countries, especially in the poorest, where the impact of vaccine-preventable disease is greatest. Of the fifteen countries in Africa reporting data to WHO for 1991 and classified as least developed nations,2thirteen reported a decline in coverage. The fall in coverage took place after a consistent rise in coverage between 1986 and 1990 (WHO unpublished data, 1992; figure). Donors and agencies supporting EPI must urgently assess the reasons for this decline, which particularly affects the most vulnerable infants and mothers. Although the adoption of ambitious disease-control targets can generate political will for public health and mobilise local resources,3 there remain many reasons for failure to sustain coverage in the poorest countries. An increasing number of low-income countries spend less than US$4 per caput each year on health services. In these countries, high coverage can only be achieved quickly if large investments in vaccines, equipment, transport, and other costs are made by foreign donors for nationwide campaigns. This strategy might increase coverage in the short term, but the weak health service infrastructure is unable to sustain these achievements. Some governments have little control over health policies and are unable to plan for long-term health services because most of the health budget is funded by foreign donors. For example, Uganda spends a total of US$3-25 per caput annually; of this US$2 comes from external donors (Paul Smithson, Save the Children Fund, unpublished data, 1992). Donors who supported immunisation programmes before 1990 are now inviting governments to assume financial responsibility for programmes they did not design. Yet under present global economic conditions, the least developed countries are estimated to be able to afford less than 30% vaccine coverage by the year 2000, even if they allocated 10% of their total expenditure on health to childhood immunisation.4 For many of the poorest countries, the resources for welfare are diminishing as a result of structural adjustment policies, debt reservicing, falling foreign exchange earnings, and loss of trained people through migration and diseases such as AIDS. At the same time needs are rising as a result of population growth, civil conflict, environmental degradation, food insecurity, and AIDS. The questions today are, is it appropriate to continue to strive for high
Percentage of infants immunised against measles by yea Low income economies
(World Development Report, 1992).
alone, and who should take such a decision? To avoid repeating the problems asssociated with overambitious global goals,san approach to planning is required that allows for the local control of decision making, considers local needs and resources, and recognises that a much longer time is needed for sustained achievement. The pledge of the EPI is to achieve 99% coverage world wide by 2000, in a way that supports the development of appropriate, affordable, comprehensive, and effective health services.6 The achievement of UCI will only be a significant public-health event if the achievements so far, in reaching vulnerable mothers and children in deteriorating circumstances, can be used both to sustain high vaccine coverage and to provide other essential health services to the highest quality.
coverage of immunisation
Policy Development and Technical Support Unit, Save the Children Fund, Camberwell, London SE5 8RD, UK
PETER POORE
Communicable Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1
FELICITY CUTTS
Policy Development and Technical Save the Children Fund, London
JOHN SEAMAN
Support Unit,
1. Universal Childhood Immunisation
by
the year 1990, Oct 8, 1991. Geneva:
WHO/UNICEF (UCI 90), 1991. development indicators. In: World development report 1992 development and the environment. Oxford: Oxford University Press, 1992. 3. de Quadros CA, Andrus JK, Olive JM, et al. The eradication of poliomyelitis: progress in the Americas. Pediatr Infect Dis J 1991; 10: 222-29. 4. Rosenthal G. The economic burden of sustainable EPI: implications for donor policy. Resources for Child Health Project, Feb, 1990. Arlington: John Snow Inc, 1990. 5. Seaman J, Poore P. Good intentions, unfortunate consequences. Lancet 1987; i; 1334. 6. World Health Assembly. WHA42/1989/REC/1,33, May, 1989. Geneva: WHO, 1989.
2 World Bank. World
Smoking and statistical overkill SIR,-Petr Skrabanek’s diatribe (Nov 14, p 1208) against those who work to reduce tobacco use and its consequent burden of disease contains some curious assumptions which should not pass unremarked. The drift of his argument is that the epidemiology of attributing early death to smoking is rubbery; smoking is pleasurable; and therefore those who seek to spoil the pleasures of smokers by having the temerity to point out the risks involved and enact dissuasive policies are misguided at best and cruel and heartless at worst. Consider the nature of most smokers’ "pleasure". Study after study reveals that large numbers of smokers wish they could stop. Many are quite aware that the pleasure they derive from smoking lies mostly in the relief of the physical and psychological discomfort they experience when they are not smoking. This is a type of pleasure that is somewhat removed from Skrabanek’s romantic framing of the cigarette as solace to the lonely. He pamts a spectre of antismokers hounding the downcast smokers of the world: the poor, the hopeless, and the lonely as they quietly palliate their offspring and bring a little pleasure into their miserable lives-very touching stuff, but a bonfire set beneath a huge straw man. Seeking to position antismokers as the moral equivalents of those who steal food aid in Somalia, he asks rhetorically what advice should be given to an arthritic, elderly widow who smokes; or someone in bereavement. Yet who but Skrabanek ever asks such questions? Where are these brigades of heartless doctors taunting such widows? Swept along by the tide of his own rhetoric, he fails to ask the obvious question at the heart of tobacco control; what advice does one give to a healthy, 13-year-old considering whether to take it up? Skrabanek gallantly defends the rights of smokers, writing of the destructive social polarisation wrought by non-smokers’ rights to avoid tobacco smoke taking precedence over that of smokers to do as they please. There is an interesting parallel here with spitting and farting. Like smoking, both acts are pleasurable and in former times, were quite socially acceptable in company.’ And like smoking, public spitting has public-health implications. Yet imagine earnest talk today of spitters’ or farters’ "rights", invested with the gravitas that Skrabanek brings to his defence of smokers’ rights.
59
There certainly are some worrying excesses at the fringes of tobacco control that seem to be inspired by values that have little to do with humanistic public health. These include policies that seek to deny prisoners and long-stay psychiatric patients access to tobacco, moves to fine and criminalise children who smoke, and the most obnoxious of all, recent (thankfully isolated) American advocacy for parental smoking to be deemed evidence in child custody battles. The best that one might hope for in Skrabanek’s regular counsel on the folly of the health educators is that he might help us all to apply the brakes to such excesses. Unfortunately, however, the more likely scenario is that his writings will continue to provide succour to those with the ethics of a cash register-the tobacco industry. Department of Community Medicine, Westmead Hospital, NSW 2145, Australia
SIMON CHAPMAN
were to be examined by two centres, and one centre’s median was greater than that of the other, the one with the higher median would be likely to fmd more patients with "screen positive" MoMs. Similarly, if both centres used the same median but estimated results in one were biased to be higher than that of the other, the method would find fewer patients with screen positive MoMs. This effect would not arise with the use of a Z score. If it is not possible to use the Z score method for standardisation, results should be presented as absolute values, for comparison with a centile plot or with an age-related reference range.
patients
Chemical Pathology Department, Royal Gwent Hospital, Newport, Gwent NP9 2UB, UK
Department of Mathematics, University of Wales,
B NIX F. DUNSTAN
Cardiff 1 Elias N. The civilizing process, vol 1: the history of manners. New York: Pantheon, 1980.
SIR,-Petr Skrabanek in his viewpoint article makes some excellent points. As a public-health physician who has had all his undergraduate and postgraduate and medical training and job experience in the USA (at Johns Hopkins Hospital, and at Harvard College) I can appreciate what he says about the overkill behind some public health campaigns. And the equivalent quip in the USA to the one in Smoking out the Barons, which Skrabanek cites, might be "If you can’t dazzle them with your brilliance, then baffle them with your M1...I". Unfortunately, the points that he so cogently makes about antismoking campaigns may also be made about other equally worthy (or unworthy depending on one’s point of view) publichealth campaigns or, maybe, the word would better be crusades. Which brings to mind the fact that there are strong similarities between the public-health issues and the respective political climates and constituencies in the UK and the USA. The best examples of statistical overkill with which I am familiar in this country are the issues of environmental hazards such as (in serious terms) asbestos and lead and (in a serious vein) the scandals over alar, ethylene dibromide, or Chilean grapes. On the other hand, the best example of politicisation of the smoking issue in the USA is the recent case of the controversy in the State of California between pro-smoking education groups and the Secretary of Health, Ms Molly Coye (June 27, p 1595). It is too bad that sceptical or variant points of view such as that described by Skrabanek are frequently censored by our media as "politically incorrect", and I applaud The Lancet for publishing such alternative opinions. 1544 Saragossa Avenue, Coral Gables, Florida 33134, USA
HENRY T. WASSERMAN
Use of MoMs in medical statistics SIR,-Dr Jobst and colleagues (Nov 14, p 1179) report a computed tomographic method for diagnosis of Alzheimer’s disease that uses multiples of the median (MoMs) to standardise for normal age-related changes in the thickness of the medial temporal lobe. In research in a different branch of medicine we use MoMs for correction of varying analyte concentrations, and we are concerned by the increasing use of MoMs in medical statistics. MoMs are a very poor method of standardisation because they are affected by the distribution of the results used to determine the median.1 Additionally, because there is no correction for the spread of the data, minor methodological changes may significantly alter the MoM, resulting in incorrect clinical decisions.2 If a method of standardisation is necessary the MoM should be preferably replaced by a Z score, which represents the number of standard deviations by which a result differs from the mean ([patient result-mean where mean and SD are locally derived population variables assuming an underlying symmetric distribution). This method is preferred even though it may need more data because the mean and SDs for different centres may vary as a result of methodological biases. For example, if a group of
T. REYNOLDS
Swift A. All MoMs are not equal: some statistical properties associated with reporting results in the form of multiples of the median Am J Hum Genet (in press). 2. Reynolds T, John R. Companson of assay kits for unconjugated esteriol shows that expressing results as multiples of the median causes unacceptable variation in calculated nsk factors for Down syndrome. Clin Chem 1992; 38: 1888-93. 1.
Bishop J, Dunstan F, Nix B, Reynolds T,
Tracheal
administration of adrenaline
or venous
SIR,-Dr McCrirrick and Dr Kestin (Oct 10, p 868) report a comparison between tracheal and intravenous adrenaline. The information gathered from their study was merely confirmatory; a previous study,1 also published in The Lancet, had indicated in realistic clinical circumstances of use that intratracheal adrenaline is ineffective and that plasma adrenaline concentrations are not raised after its use.2 It is thus already accepted that the intratracheal route is unreliable for the administration of this drug. McCrirrick and Kestin conclude that larger doses might be effective, but such a study would be unethical. How can a study like this receive approval by an ethics committee? Total hip replacement is not often done on young patients and although we are not told the ages of the patients they were probably not young. It might therefore be argued that the patients’ chances of an unheralded subarachnoid haemorrhage as a result of a surge in systolic blood pressure were modest; nevertheless most anaesthetists try to avoid such striking changes. These patients were anaesthetised by a combined general and regional technique, which probably protected them from arrhythmias but incidentally reduced the systolic pressure to 80-90 mm Hg. The intravenous use of adrenaline caused in 92% patients a substantial rise in systolic arterial blood pressure of an average of 40mm Hg and in one patient of 81 mm Hg. Finally the study could not confer therapeutic benefit on these patients or on any other because adrenaline would not be used in this fashion. Had the advice in your editorial of a few months ago3 been heeded a scientific committee would probably have suggested that this study was not worth doing and was in any case likely to be in conflict with the general code of ethics that governs clinical investigation. Department of Anaesthetics, University of Wales College of Medicine, Cardiff CF4 4XN, UK
JOHN N. LUNN
1. Quinton DN, O’Byme G, Aitkenhead AR. Comparison of endotracheal and peripheral intravenous adrenaline in cardiac arrest: is the endotracheal route reliable? Lancet 1987; i: 828-29. 2. Aitkenhead AR. Drug administration during CPR: What route? Resuscitation 1991; 22: 191-95. 3. Ethics and clinical research in anaesthesia. Lancet
1992; 339: 337-38.
Authors’reply SIR,-We disagree with Dr Lunn’s assertion that it is generally accepted that tracheal adrenaline is ineffective. Resuscitation guidelines continue to recommend the tracheal administration of adrenaline should intravenous access not be readily available, despite the work of Quinton and co-workers.We believe that most doctors are unaware of the drawbacks with intratracheal adrenaline and continue to use it in cardiac arrest.
Universal Childhood Immunisation: is it sustainable? SIR,-One year after the official declaration of Universal Childhood Immunisation (UCI), there is a need to assess the sustainability of the success of the WHO Expanded Programme on Immunisation (EPI). The goal of UCI by the year 1990 was adopted at the World Health Assembly in 1977. On Oct 8, 1991, it was declared that the goal had been reached: official reports showed that 80% of the world’s infants had been vaccinated.l Since 1990, however, coverage has fallen in many countries, especially in the poorest, where the impact of vaccine-preventable disease is greatest. Of the fifteen countries in Africa reporting data to WHO for 1991 and classified as least developed nations,2thirteen reported a decline in coverage. The fall in coverage took place after a consistent rise in coverage between 1986 and 1990 (WHO unpublished data, 1992; figure). Donors and agencies supporting EPI must urgently assess the reasons for this decline, which particularly affects the most vulnerable infants and mothers. Although the adoption of ambitious disease-control targets can generate political will for public health and mobilise local resources,3 there remain many reasons for failure to sustain coverage in the poorest countries. An increasing number of low-income countries spend less than US$4 per caput each year on health services. In these countries, high coverage can only be achieved quickly if large investments in vaccines, equipment, transport, and other costs are made by foreign donors for nationwide campaigns. This strategy might increase coverage in the short term, but the weak health service infrastructure is unable to sustain these achievements. Some governments have little control over health policies and are unable to plan for long-term health services because most of the health budget is funded by foreign donors. For example, Uganda spends a total of US$3-25 per caput annually; of this US$2 comes from external donors (Paul Smithson, Save the Children Fund, unpublished data, 1992). Donors who supported immunisation programmes before 1990 are now inviting governments to assume financial responsibility for programmes they did not design. Yet under present global economic conditions, the least developed countries are estimated to be able to afford less than 30% vaccine coverage by the year 2000, even if they allocated 10% of their total expenditure on health to childhood immunisation.4 For many of the poorest countries, the resources for welfare are diminishing as a result of structural adjustment policies, debt reservicing, falling foreign exchange earnings, and loss of trained people through migration and diseases such as AIDS. At the same time needs are rising as a result of population growth, civil conflict, environmental degradation, food insecurity, and AIDS. The questions today are, is it appropriate to continue to strive for high
Percentage of infants immunised against measles by yea Low income economies
(World Development Report, 1992).
alone, and who should take such a decision? To avoid repeating the problems asssociated with overambitious global goals,san approach to planning is required that allows for the local control of decision making, considers local needs and resources, and recognises that a much longer time is needed for sustained achievement. The pledge of the EPI is to achieve 99% coverage world wide by 2000, in a way that supports the development of appropriate, affordable, comprehensive, and effective health services.6 The achievement of UCI will only be a significant public-health event if the achievements so far, in reaching vulnerable mothers and children in deteriorating circumstances, can be used both to sustain high vaccine coverage and to provide other essential health services to the highest quality.
coverage of immunisation
Policy Development and Technical Support Unit, Save the Children Fund, Camberwell, London SE5 8RD, UK
PETER POORE
Communicable Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1
FELICITY CUTTS
Policy Development and Technical Save the Children Fund, London
JOHN SEAMAN
Support Unit,
1. Universal Childhood Immunisation
by
the year 1990, Oct 8, 1991. Geneva:
WHO/UNICEF (UCI 90), 1991. development indicators. In: World development report 1992 development and the environment. Oxford: Oxford University Press, 1992. 3. de Quadros CA, Andrus JK, Olive JM, et al. The eradication of poliomyelitis: progress in the Americas. Pediatr Infect Dis J 1991; 10: 222-29. 4. Rosenthal G. The economic burden of sustainable EPI: implications for donor policy. Resources for Child Health Project, Feb, 1990. Arlington: John Snow Inc, 1990. 5. Seaman J, Poore P. Good intentions, unfortunate consequences. Lancet 1987; i; 1334. 6. World Health Assembly. WHA42/1989/REC/1,33, May, 1989. Geneva: WHO, 1989.
2 World Bank. World
Smoking and statistical overkill SIR,-Petr Skrabanek’s diatribe (Nov 14, p 1208) against those who work to reduce tobacco use and its consequent burden of disease contains some curious assumptions which should not pass unremarked. The drift of his argument is that the epidemiology of attributing early death to smoking is rubbery; smoking is pleasurable; and therefore those who seek to spoil the pleasures of smokers by having the temerity to point out the risks involved and enact dissuasive policies are misguided at best and cruel and heartless at worst. Consider the nature of most smokers’ "pleasure". Study after study reveals that large numbers of smokers wish they could stop. Many are quite aware that the pleasure they derive from smoking lies mostly in the relief of the physical and psychological discomfort they experience when they are not smoking. This is a type of pleasure that is somewhat removed from Skrabanek’s romantic framing of the cigarette as solace to the lonely. He pamts a spectre of antismokers hounding the downcast smokers of the world: the poor, the hopeless, and the lonely as they quietly palliate their offspring and bring a little pleasure into their miserable lives-very touching stuff, but a bonfire set beneath a huge straw man. Seeking to position antismokers as the moral equivalents of those who steal food aid in Somalia, he asks rhetorically what advice should be given to an arthritic, elderly widow who smokes; or someone in bereavement. Yet who but Skrabanek ever asks such questions? Where are these brigades of heartless doctors taunting such widows? Swept along by the tide of his own rhetoric, he fails to ask the obvious question at the heart of tobacco control; what advice does one give to a healthy, 13-year-old considering whether to take it up? Skrabanek gallantly defends the rights of smokers, writing of the destructive social polarisation wrought by non-smokers’ rights to avoid tobacco smoke taking precedence over that of smokers to do as they please. There is an interesting parallel here with spitting and farting. Like smoking, both acts are pleasurable and in former times, were quite socially acceptable in company.’ And like smoking, public spitting has public-health implications. Yet imagine earnest talk today of spitters’ or farters’ "rights", invested with the gravitas that Skrabanek brings to his defence of smokers’ rights.
59
There certainly are some worrying excesses at the fringes of tobacco control that seem to be inspired by values that have little to do with humanistic public health. These include policies that seek to deny prisoners and long-stay psychiatric patients access to tobacco, moves to fine and criminalise children who smoke, and the most obnoxious of all, recent (thankfully isolated) American advocacy for parental smoking to be deemed evidence in child custody battles. The best that one might hope for in Skrabanek’s regular counsel on the folly of the health educators is that he might help us all to apply the brakes to such excesses. Unfortunately, however, the more likely scenario is that his writings will continue to provide succour to those with the ethics of a cash register-the tobacco industry. Department of Community Medicine, Westmead Hospital, NSW 2145, Australia
SIMON CHAPMAN
were to be examined by two centres, and one centre’s median was greater than that of the other, the one with the higher median would be likely to fmd more patients with "screen positive" MoMs. Similarly, if both centres used the same median but estimated results in one were biased to be higher than that of the other, the method would find fewer patients with screen positive MoMs. This effect would not arise with the use of a Z score. If it is not possible to use the Z score method for standardisation, results should be presented as absolute values, for comparison with a centile plot or with an age-related reference range.
patients
Chemical Pathology Department, Royal Gwent Hospital, Newport, Gwent NP9 2UB, UK
Department of Mathematics, University of Wales,
B NIX F. DUNSTAN
Cardiff 1 Elias N. The civilizing process, vol 1: the history of manners. New York: Pantheon, 1980.
SIR,-Petr Skrabanek in his viewpoint article makes some excellent points. As a public-health physician who has had all his undergraduate and postgraduate and medical training and job experience in the USA (at Johns Hopkins Hospital, and at Harvard College) I can appreciate what he says about the overkill behind some public health campaigns. And the equivalent quip in the USA to the one in Smoking out the Barons, which Skrabanek cites, might be "If you can’t dazzle them with your brilliance, then baffle them with your M1...I". Unfortunately, the points that he so cogently makes about antismoking campaigns may also be made about other equally worthy (or unworthy depending on one’s point of view) publichealth campaigns or, maybe, the word would better be crusades. Which brings to mind the fact that there are strong similarities between the public-health issues and the respective political climates and constituencies in the UK and the USA. The best examples of statistical overkill with which I am familiar in this country are the issues of environmental hazards such as (in serious terms) asbestos and lead and (in a serious vein) the scandals over alar, ethylene dibromide, or Chilean grapes. On the other hand, the best example of politicisation of the smoking issue in the USA is the recent case of the controversy in the State of California between pro-smoking education groups and the Secretary of Health, Ms Molly Coye (June 27, p 1595). It is too bad that sceptical or variant points of view such as that described by Skrabanek are frequently censored by our media as "politically incorrect", and I applaud The Lancet for publishing such alternative opinions. 1544 Saragossa Avenue, Coral Gables, Florida 33134, USA
HENRY T. WASSERMAN
Use of MoMs in medical statistics SIR,-Dr Jobst and colleagues (Nov 14, p 1179) report a computed tomographic method for diagnosis of Alzheimer’s disease that uses multiples of the median (MoMs) to standardise for normal age-related changes in the thickness of the medial temporal lobe. In research in a different branch of medicine we use MoMs for correction of varying analyte concentrations, and we are concerned by the increasing use of MoMs in medical statistics. MoMs are a very poor method of standardisation because they are affected by the distribution of the results used to determine the median.1 Additionally, because there is no correction for the spread of the data, minor methodological changes may significantly alter the MoM, resulting in incorrect clinical decisions.2 If a method of standardisation is necessary the MoM should be preferably replaced by a Z score, which represents the number of standard deviations by which a result differs from the mean ([patient result-mean where mean and SD are locally derived population variables assuming an underlying symmetric distribution). This method is preferred even though it may need more data because the mean and SDs for different centres may vary as a result of methodological biases. For example, if a group of
T. REYNOLDS
Swift A. All MoMs are not equal: some statistical properties associated with reporting results in the form of multiples of the median Am J Hum Genet (in press). 2. Reynolds T, John R. Companson of assay kits for unconjugated esteriol shows that expressing results as multiples of the median causes unacceptable variation in calculated nsk factors for Down syndrome. Clin Chem 1992; 38: 1888-93. 1.
Bishop J, Dunstan F, Nix B, Reynolds T,
Tracheal
administration of adrenaline
or venous
SIR,-Dr McCrirrick and Dr Kestin (Oct 10, p 868) report a comparison between tracheal and intravenous adrenaline. The information gathered from their study was merely confirmatory; a previous study,1 also published in The Lancet, had indicated in realistic clinical circumstances of use that intratracheal adrenaline is ineffective and that plasma adrenaline concentrations are not raised after its use.2 It is thus already accepted that the intratracheal route is unreliable for the administration of this drug. McCrirrick and Kestin conclude that larger doses might be effective, but such a study would be unethical. How can a study like this receive approval by an ethics committee? Total hip replacement is not often done on young patients and although we are not told the ages of the patients they were probably not young. It might therefore be argued that the patients’ chances of an unheralded subarachnoid haemorrhage as a result of a surge in systolic blood pressure were modest; nevertheless most anaesthetists try to avoid such striking changes. These patients were anaesthetised by a combined general and regional technique, which probably protected them from arrhythmias but incidentally reduced the systolic pressure to 80-90 mm Hg. The intravenous use of adrenaline caused in 92% patients a substantial rise in systolic arterial blood pressure of an average of 40mm Hg and in one patient of 81 mm Hg. Finally the study could not confer therapeutic benefit on these patients or on any other because adrenaline would not be used in this fashion. Had the advice in your editorial of a few months ago3 been heeded a scientific committee would probably have suggested that this study was not worth doing and was in any case likely to be in conflict with the general code of ethics that governs clinical investigation. Department of Anaesthetics, University of Wales College of Medicine, Cardiff CF4 4XN, UK
JOHN N. LUNN
1. Quinton DN, O’Byme G, Aitkenhead AR. Comparison of endotracheal and peripheral intravenous adrenaline in cardiac arrest: is the endotracheal route reliable? Lancet 1987; i: 828-29. 2. Aitkenhead AR. Drug administration during CPR: What route? Resuscitation 1991; 22: 191-95. 3. Ethics and clinical research in anaesthesia. Lancet
1992; 339: 337-38.
Authors’reply SIR,-We disagree with Dr Lunn’s assertion that it is generally accepted that tracheal adrenaline is ineffective. Resuscitation guidelines continue to recommend the tracheal administration of adrenaline should intravenous access not be readily available, despite the work of Quinton and co-workers.We believe that most doctors are unaware of the drawbacks with intratracheal adrenaline and continue to use it in cardiac arrest.