1 Portland, USA 2 Hong Kong, China
EditorWhile I congratulate Mak and Ooi on their ingenious management of a patient with ß-thalassaemia major undergoing maxillary and mandibular osteotomies by means of an elective submental intubation,1 I would like to raise one important advantage of a tracheostomy in this situation which was not addressed. A tracheostomy was apparently discounted as an aesthetically inferior option by both patient and surgeon. This may be so, but the patient required oral intubation at the end of the procedure and 2 days of ventilatory support in the ICU. I presume this may have necessitated the use of sedation to enable compliance with the oral tracheal tube. A tracheostomy may have circumvented the need for any sedation if respiratory support per se was not required and supplemental oxygen could be delivered by mask. This could have shortened the patients ICU stay if no other complications supervened. I do not wish to criticize the authors skilful management in this case, but I would be interested to learn whether the patient was appraised of the greater likelihood of needing prolonged respiratory support if submental intubation were chosen?
T. R. Johnson
Portland, USA
EditorWe thank Dr Johnson for his comments. We agree that differences in compliance between a tracheostomy and an oral tracheal tube pose a distinct advantage, in terms of duration of ICU stay, in favour of a tracheostomy, because of reduced sedation requirements. Whether this argument is valid for the submental route is still unclear because of the lack of documented experience with the technique. Consequently, we did not raise this point with the patient, particularly when the initial plan was to leave the tracheal tube in place via the submental route postoperatively. What was emphasized to the patient was the safety record of tracheostomies, their ease of placement and patient tolerance, as well as the familiarity of staff with their use.
P. H. K. Mak
R. G. B. Ooi
Hong Kong, China
References
1 Mak PHK, Ooi RGB. Submental intubation in a patient with beta-thalassaemia major undergoing elective maxillary and mandibular antrostomies. Br J Anaesth 2002; 88: 28891