Talk:Tracheal intubation/GA1

GA Review
The edit link for this section can be used to add comments to the review.''

Reviewer: Sasata (talk) 15:57, 1 August 2010 (UTC)

Hi, I've signed up for this review. Before we get going, could you ensure that all paragraphs are cited? There are numerous paragraphs without any sources, and this is unacceptable for a Good Article (or GAN, really). If you can get this done in the next week or so, great; if not, it might be better to withdraw the GAN to work on it some more. Sasata (talk) 15:57, 1 August 2010 (UTC)


 * Hello Sasata, and thank you for your unexpectedly rapid response to my GAN. Seeing the backlog, I figured I had some time to tidy things up before anyone got around to looking at this article. As you will see, I have made many changes to the article today, including major rewrites of the lead section and several other sections. I was unaware of the requirement that all paragraphs need to be cited. As per your request, all paragraphs are now cited. DiverDave (talk) 05:45, 2 August 2010 (UTC)
 * Thanks for the rapid fixes. I'll start reviewing the article soon and hope to have some comments up in a few days. BTW, I chose this article for review as my wife, as an anesthesiologist, is an airway specialist and has intimate knowledge of the procedures and techniques discussed in the article, so I figured I should "take advantage" of this handy resource :) Sasata (talk) 18:10, 2 August 2010 (UTC)
 * I look forward to all input from you and your wife, Sasata. No doubt your wife will be able to identify areas in need of improvement. If she is not already a Wikipedian, perhaps this article will give her a good opportunity to start making some edits of her own. :) DiverDave (talk) 21:25, 3 August 2010 (UTC)

I looked at the article before Sasata kindly agreed to do the review. Dave, would you also have a look at Images which advices that images should be right-justified unless there's a good reason not to. There's a related issue with having a right-justified image displayed immediately under a section header. The section Laryngoscopes also falls foul of MOS:IMAGES which advises us to "avoid sandwiching text between two images that face each other". Hope that helps. --RexxS (talk) 23:20, 1 August 2010 (UTC)
 * One other thing I forgot: the section Tracheotomy is effectively empty. Check WP:Manual of Style (summary style) and Template:Main; that section should contain a summary of the article Tracheotomy if you're using Main or Details, or a summary of the relevant parts if you use See or Further. --RexxS (talk) 23:57, 1 August 2010 (UTC)


 * Hello RexxS, and thank you also for your rapid response to my GAN. In accordance with your suggestions and MOS:IMAGES:


 * 1) all image files except for two are now right-justified . The reason for the two images that remain left-justified is that right-justification would create unnecessary and distracting whitespace in the article. Furthermore, this would displace the images so that they would appear in the wrong sections/subsections. I have considered deleting images, but IMHO every image file in this article serves an important purpose.
 * 2) I have changed all image file sizes to 220 px.
 * 3) the section Tracheotomy is no longer empty. DiverDave (talk) 05:45, 2 August 2010 (UTC)
 * Good work. It's always a problem balancing whitespace against image use, and sometimes there's no perfect solution as we can't control the size of the browser window that readers use. I've tested the current page at various sizes and although the facing images squash the text somewhat at 800x600, it's not too bad at 1024x768 and otherwise looks fine all the way up to 1920x1200. I've set all the images to default size (don't specify number of px), so they will render at 220px wide for 99% of viewers, but it does allow registered editors to have a different default if they choose in their preferences. I also removed the |right parameter where appropriate, as that's the default as well, but that's no big deal. I did find one other section that has no text: Nasotracheal intubation, so you should look at that to see if it needs text or if the section levels need to be altered. Anyway, good luck with your GAN, and feel free to ping me or leave a message at the Doctors' Mess if there's anything I can help with. --RexxS (talk) 18:03, 2 August 2010 (UTC)
 * Thank you RexxS for fixing all of those image files and reviewing the article appearance at different resolutions---that is a little beyond my current capability. I have removed the empty Nasotracheal intubation subsection for now, as this article is possibly already getting to be too lengthy. DiverDave (talk) 21:25, 3 August 2010 (UTC)

A mostly unrelated comment on the references: was there a change in WP:MED referencing style? I thought we tried to use PMIDs whenever possible (in addition/alternative to DOId), but usually did not use ISSNs (I only use them for ambiguous or fairly obscure publications). Circéus (talk) 19:02, 2 August 2010 (UTC)
 * Thanks for your comment, Circeus. I am still sort of a newbie here, especially when it comes to details such as the formatting of references. However, I certainly wish to conform to whatever format has been agreed upon by previous consensus. I have tried very hard to include PMID and DOI codes for as many sources as possible, but such codes do not appear to be available in all cases. I have read through most of what I can find at WP:MED, and have not yet seen any discussion on whether to include or exclude ISSN or PMCID codes. I have included them in 10 of roughly 122 sources, only in the interest of being as thorough as possible. 7 of these 10 sources also have PMID and DOI codes, so I do not think deleting the ISSN would be a problem. The remaining 3 sources however (Rajesh-2006, Shehata-2003, and Trousseau-1858) have no DOI or PMID codes, so in these caes at least it seems we should retain the ISSN codes. What do you think? Regards, DiverDave (talk) 21:06, 3 August 2010 (UTC)
 * I wouldn't flunk a GA nom on the basis of overlinking in the references anyway. I just figured asking while thorough reviewing was underway. I actually like to streamline references, and wouldn't mind doing so after the article has gone through GA. Doing it, however is far more practical under list-defined references, a switch that is very impolite to do without permission (plus I fully admit adding references "traditionally" is more practical when an article is under heavy editing). SO if you want me to have a go, just leave me a message when the edit flurry is over :P Circéus (talk) 02:32, 7 August 2010 (UTC)


 * Comments: I've added a number of citation needed tags throughout, especially for uncited sentences appearing at the end of paragraphs. My wife made a bunch of notes on a copy of the article I printed out for her, but they are mostly undecipherable, and I will have to consult with her before I post them here :) Are you planning to bring this article to FAC? If so I will spend some extra time with reference formatting (if you're interested, that is), otherwise it's mostly good enough for GA. More later. Sasata (talk) 16:45, 6 August 2010 (UTC)
 * History
 * suggest linking carotid artery, asphyxiation, thorax, indication (all items now linked) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * gloss definition for esophagogastroduodenoscopy (esophagogastroduodenoscopy has been defined) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * metric measurements need imperial conversions throughout article (conversion templates have been applied) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * "In 1854, a singing teacher named Manuel Garcia" Singing teacher? Perhaps a teacher of singing? Do we need to link the common word singing and teacher? (changed to vocal pedagogist. I hate to use words like this, but the link is to a pretty good article, and I want the reader to understand that Garcia was actually a fairly prominent figure in the history of laryngology and laryngoscopy.) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * unlink sun (Sun has been unlinked) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * "…securing it by means of a silk thread and leaving it there for a few days." ? please clarify why leaving it there for a few days was essential to his procedure (...leaving it there for a few days until the pseudomembrane and airway obstruction had resolved sufficiently.) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * "In March 1878, Wilhelm Hack of Freiburg, Germany reported the use of non-surgical orotracheal intubation in the removal of vocal cord polyps.[45] In November of that year, he reported the use of orotracheal intubation…" perhaps reword to remove repetitive "reported the use of" (in the following sentence too) (...published a paper describing the use of...) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * Indications
 * patency has not been defined (patency: the relative absence of blockage) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * "In such situations, tracheal intubation restores airway patency and protects the lower airways from aspiration." This final sentence of paragraph is uncited (inline citation moved to cover final sentence) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * why give only the details of the Mallampati score and not the two other classification systems for determining difficulty of intubation? (Because the Mallampati score is by far the most well-known in the U.S. and international medical communities) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * "While perfection may be an unrealistic expectation from a statistical standpoint, the grave consequences of failed tracheal intubation require the highest possible degree of certainty in predicting the difficulty of intubation." Another end-of-paragraph uncited sentence (uncited sentence has been removed) DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * see WP:caption, under subheading "Wording" if it's unclear why I removed fullstops from several image captions
 * Special situations
 * "proper use of the Sellick maneuver can minimize the occurrence of this dreaded complication." It may be dreaded, but we should avoid interjecting these emotive descriptions in our encyclopedic writing :) (removed the word "dreaded") DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * what's a tracheal toilet? (replaced "tracheal toilet" with "removal of tracheal secretions") DiverDave (talk) 06:47, 7 August 2010 (UTC)


 * Thanks for your suggestions, Sasata. I hope I have addressed most of them to your satisfaction. I will get to the tags tomorrow (I gotta get some sleep now). I am still looking forward to your wife's comments. I have never brought an article to FAC before, but if you think this one has a shot, then perhaps I should proceed in that direction. I am willing to do whatever it takes to get the references correctly formatted. I have been struggling with this issue for 2 years now, so maybe it is time for me to finally grab the bull by the horns. From what I can see of your contributions thus far, you would be a most excellent mentor for this endeavor! DiverDave (talk) 06:47, 7 August 2010 (UTC)
 * I have just completed addressing all of the above-mentioned problem areas, including all tags. I will await your further input. DiverDave (talk) 03:57, 10 August 2010 (UTC)


 * Content review Content generally looks good according to the expert. Just a few comments and suggestions below: Sasata (talk) 04:56, 11 August 2010 (UTC)
 * "Indications":
 * "... although there are alternative devices such as the laryngeal mask airway[85] or the CPAP mask." The way it is written, it might be misinterpreted that the laryngeal mask airway or the CPAP mask are forms of intubation, but they are not. It is correct, however, that they can be used to accomplish some of the listed diagnostic or therapeutic manipulations of the airway. (removed potentially misleading statement, rewrote and condensed section to 2 paragraphs) DiverDave (talk) 14:30, 20 August 2010 (UTC)


 * "Equipment":
 * Suggest to also give the number associated with each size of Miller blade (large adult=4, small adult=3, pediatric=2, infant=1, neonate=0, as these blades are commonly referred to these values in clinical practice ("Nurse, pass me a Miller 3 and a Mac 4, Stat!"). (added sentence describing sizes of available laryngoscope blades) DiverDave (talk) 14:30, 20 August 2010 (UTC)


 * "Other noninvasive" devices which are often employed for tracheal intubation are the laryngeal mask airway" Non-invasive devices do not accomplish tracheal intubation; however, the intubating laryngeal mask airway (commonly abbreviated intubating LMA) can be used as an assist device to accomplish intubation. Suggest to word like so: "Other "noninvasive" devices which are employed to assist in tracheal intubation are the intubating laryngeal mask airway" (reworded sentence a bit, added more inline citations. Clarified use of LMA as an assist device, etc. One can intubate the trachea through most LMA devices; the intubating LMA is not necessary to accomplish this. See references.) DiverDave (talk) 14:30, 20 August 2010 (UTC)
 * The Cook Airway Exchange Catheter is also notable because it can deliver O2 (or any gas you want, but of course O2 is most common) in emergency situations. (added text: this device is notable for having a central lumen through which oxygen can be insufflated.) DiverDave (talk) 14:30, 20 August 2010 (UTC)
 * "Special situations":
 * "…the Sellick maneuver (sometimes referred to as the application of cricoid pressure) is a method of preventing regurgitation and pulmonary aspiration of gastric contents, in addition to helping to bring the glottis into view during laryngoscopy and tracheal intubation." This is incorrect, and this sentence is contradicted later in the paragraph with "as well as compressing the glottis to a variable extent, which can obstruct the view of the laryngoscopist". BURP (Backwards Upwards Rightwards Pressure) is used for improving the view, but has no place in RSI. My wife explains that this is a common misunderstanding, even the nurses assisting with intubations get it wrong occasionally. (added text distinguishing between Sellick and BURP maneuvers, and the situations in which they are used) DiverDave (talk) 14:55, 20 August 2010 (UTC)


 * "Cricothyrotomy"
 * In addition to the view obstruction noted already, new literature indicates that Sellick's Manouevre does not reduce aspiration during RSI, which was its main reason to be used. However, this point is very contentious among the experts, and some are stuck in their old ways. (I have completely rewritten this section, and added a bulleted list indicating some of the points of contention with respect to the use of the Sellick maneuver in RSI) DiverDave (talk) 14:55, 20 August 2010 (UTC)
 * It should be mentioned that kits are availble to perform surgical cricothyrotomy, and they are commonly stocked in hospitals for emergency situations. Check out here for an example. (I have added this text in the ==Tracheotomy== section, as well as added links in the ==External links== section) DiverDave (talk) 23:00, 29 August 2010 (UTC)


 * the second paragraph of "Complications" is somewhat tedious to read, as much of it is a list. Might there be a way to group these complications in some way and discuss them a bit? Any statistics on how often these complications occur? (I have rearranged this section a bit. Complications are now grouped as those resulting from the act of laryngoscopy and intubation versus those resulting from prolonged tracheal intubation) DiverDave (talk) 14:55, 20 August 2010 (UTC)


 * I uploaded a picture (File:Macintosh Blades.jpg) that shows the complete range of sizes of Mac blades; don't feel obliged to use it though. Sasata (talk) 03:14, 13 August 2010 (UTC) (I have replaced the older/incomplete image of MAC blades with the one you uploaded) DiverDave (talk) 14:55, 20 August 2010 (UTC)

Hi Dave, I'll be away for about five or six days. Will resume the review when I get back. Cheers, Sasata (talk) 14:39, 14 August 2010 (UTC)

Dave: looking good, we're almost there. I've added some more citation needed tags to end-of-paragraph statements that don't appear to be sourced. Sorry to be a stickler about this, but if the info in a paragraph is cited except for the final sentence, it's difficult to know if the sentence is the editor's opinion or comes from a reliable source. It will also make for a smoother ride at FAC—medical articles are (rightfully) held to a higher standard of sourcing. Sasata (talk) 19:51, 22 August 2010 (UTC) (I believe I have finally addressed all of the concerns you have raised, though I wonder if 200 references might be a bit excessive....) DiverDave (talk) 09:47, 28 August 2010 (UTC)
 * Nah, it's an extremely well-sourced and valuable internet resource on a common medical procedure :) I'll give it a final read-through/copyedit in the next day or two. One thing that will have to be done for FAC considerations is to completely standarize the references so that they are displayed consistently. The specific details aren't as important as ensuring they are consistent throughout. If you want to burn a few hours you might consider switching to list-defined references, but that's by no means necessary, it just makes it easier to edit the article text in the future. Specific things to tweak:
 * author display, eg. A.I.J. Brain vs. Brain A. Period or not after the last author initial before the year?
 * journal titles abbreviated or written in full?
 * page range format: 313–315 or 313–15 or 313–5?
 * et al. after listing three author (e.g. current ref #30), or list them all (e.g. ref #42 has five authors)

Of course, these minor formatting details have no bearing on the GAN, for which the referencing is already compliant enough to the MOS. Additionally, I don't think that the "Free Dictionary" site (current ref #143) would pass muster at FAC as a RS, but it should be easy to replace. Sasata (talk) 06:36, 29 August 2010 (UTC)
 * FWIW I've already offered to do a thorough sweep of the references. Circéus (talk) 14:36, 29 August 2010 (UTC)
 * Thank you very much for your offer to help, Circeus. I cringe at the idea of personally undertaking any more major tampering with the references section. Now is probably a good time for some knowledgeable editor (hopefully you) to bring the references section into conformity with WikiProject Medicine guidelines (apparently, list-defined references is the way to go here). It seems that we will attempt to drag this through the FA process at some point, so any and all suggestions you may have will be most welcome. DiverDave (talk) 17:22, 29 August 2010 (UTC)

A few more thoughts: Sasata (talk) 17:58, 29 August 2010 (UTC)
 * the lead will have to be revisited to ensure it summarizes the contents of the article, and so that there's no info in there not in the body of the article. For example, the last paragraph of the lead discusses various things not mentioned later (e.g. T-piece, extubation, decannulation)
 * "The current perioperative mortality rate for tracheotomy is less than 1%." USA? worldwide? (I have included more specific complication and mortality rates from Spain, Netherlands, and USA. Hopefully this is representative enough for most readers.) DiverDave (talk) 23:00, 29 August 2010 (UTC)
 * be careful about overlinking; make sure that a linked term is something that a reader might click on to increase their understanding of this article (e.g., no need to link countries, common well-known items like candle or chimney, etc.) (I have unlinked most common terms IAW Manual of Style.) DiverDave (talk) 23:00, 29 August 2010 (UTC)

Dave, thanks for the hard work you've put into this important article. It certainly meets the GA criteria, and after Circéus is done with the refs, will be very close to FA quality. I'd recommend another copyedit from someone who hasn't read it yet, as it's a lengthy article and likely that we missed some minor prose issues. Good luck at the FAC! (p.s. don't forget to revise the lead) Sasata (talk) 17:42, 1 September 2010 (UTC) (I have revised the lead section) DiverDave (talk) 11:34, 3 September 2010 (UTC)


 * 1) It is reasonably well written.
 * a (prose): b (MoS):
 * Prose is well-written; article complies with MOS.


 * 1) It is factually accurate and verifiable.
 * a (references): b (citations to reliable sources): c(OR):
 * Well-referenced to reliable sources, including a large proportion of secondary sources. I source-checked some random citations and all was good.
 * 1) It is broad in its coverage.
 * a (major aspects): b (focused):
 * Coverage of the topic is thorough.
 * 1) It follows the neutral point of view policy.
 * Fair representation without bias:
 * 1) It is stable.
 * No edit wars etc.:
 * 1) It is illustrated by images, where possible and appropriate.
 * a (images are tagged and non-free images have fair use rationales): b (appropriate use with suitable captions):
 * All images are PD, or have appropriate free use licenses.
 * 1) Overall:
 * Pass/Fail:
 * 1) Overall:
 * Pass/Fail:

Bold text
Seems like there is a little too much bolding in this article. Also the image in the info box is not large enough. Wondering if a better one could be found / created. Doc James (talk · contribs · email) 13:13, 4 September 2010 (UTC)


 * Thank you for drawing my attention to this problem, Jmh649. I have removed all bolding except for that which appears in the first sentence of the article. With respect to the image size in the infobox, I am not sure what to do about that. I have not seen any guidelines wrt appropriate image size either. I have searched wikimedia commons, and have not found a more suitable image for the infobox. DiverDave (talk) 06:51, 6 September 2010 (UTC)