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Correspondence  |   November 2003
Fiberoptic Intubation: Troubles with the “Tube”?: In Reply:—
Author Notes
  • Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Article Information
Correspondence
Correspondence   |   November 2003
Fiberoptic Intubation: Troubles with the “Tube”?: In Reply:—
Anesthesiology 11 2003, Vol.99, 1237. doi:
Anesthesiology 11 2003, Vol.99, 1237. doi:
In Reply:—
I appreciate the questions posed by Drs. Wheeler and Dsida and the points raised by Drs. Ho, Chung, and Karmakar regarding our study. 1 
Drs. Wheeler and Dsida raise the question about orientation of the endotracheal tube during intubation: All tubes were initially introduced oriented in the “natural” way, meaning with the concavity facing downward toward the lower teeth, tongue, and epiglottis. The orientation of the endotracheal tube was maintained during the passage through the larynx. The bevel of the standard tube was thus facing the left side of the patient (fig. 1), so that in a 90-degree counterclockwise rotation the bevel would face posteriorly (i.e.  , “down” when the patient is lying supine). The Parker Flex-Tip tube has a symmetrical bevel that faces toward the convex side of the tube (fig. 1), meaning that during the initial attempt at intubation it was facing posteriorly during its passage through larynx.
Fig. 1. The tubes were initially introduced oriented in the “natural” way, meaning with the concavity facing downward toward the lower teeth, tongue, and epiglottis. In this position, the bevel of the standard tube (S  ) is facing the left side of the patient. The Parker Flex-Tip (PFT  ) tube has a symmetrical bevel that faces toward the convex side of the tube.
Fig. 1. The tubes were initially introduced oriented in the “natural” way, meaning with the concavity facing downward toward the lower teeth, tongue, and epiglottis. In this position, the bevel of the standard tube (S 
	) is facing the left side of the patient. The Parker Flex-Tip (PFT 
	) tube has a symmetrical bevel that faces toward the convex side of the tube.
Fig. 1. The tubes were initially introduced oriented in the “natural” way, meaning with the concavity facing downward toward the lower teeth, tongue, and epiglottis. In this position, the bevel of the standard tube (S  ) is facing the left side of the patient. The Parker Flex-Tip (PFT  ) tube has a symmetrical bevel that faces toward the convex side of the tube.
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Regarding rotation of the endotracheal tube: The technique of withdrawing the tube and rotating it 90 degrees counterclockwise, in case of resistance to introduction of the endotracheal tube through the larynx during oral fiberoptic intubation, is indeed useful. The technique was described in letters by Schwartz et al.  2 and Katsnelson et al.  , 3 was later used in nonobserver-blinded studies, 4–6 and has been confirmed in the present double-blinded study. 1 
The question is raised whether the tube should be prerotated 90 degrees counterclockwise on the fiberscope before starting the intubation attempt. I did not study this, so I do not know how it would have influenced the findings. However, many (most?) anesthesiologists have sparse experience in fiberoptic intubation, despite the availability of the fiberscope 7; thus, they cannot be expected to know all of the “tricks,” for example, rotation of the tube. The majority of anesthesiologists will most likely benefit from an endotracheal tube that leads to a high rate of success in the first attempt without the need for manipulation, such as the Parker Flex-Tip tube. 1 
References
Kristensen MS: The Parker Flex-Tip tube versus a standard tube for fiberoptic orotracheal intubation: A randomized double-blind study. A nesthesiology 2003; 98: 354–8Kristensen, MS
Schwartz D, Johnson C, Roberts J: A maneuver to facilitate flexible fiberoptic intubation (letter). A nesthesiology 1989; 71: 470–1Schwartz, D Johnson, C Roberts, J
Katsnelson T, Frost EAM, Farcon E, Goldiner PL: When the endotracheal tube will not pass over the flexible fiberoptic bronchoscope (letter). A nesthesiology 1992; 76: 151–2Katsnelson, T Frost, EAM Farcon, E Goldiner, PL
Jones HE, Pearce AC, Moore P: Fiberoptic intubation: Influence of tracheal tube tip design. Anaesthesia 1993; 48: 672–4Jones, HE Pearce, AC Moore, P
Brull SJ, Wiklund R, Ferris C, Connelly NR, Ehrenwerth J, Silverman DG: Facilitation of fiberoptic orotracheal intubation with a flexible tracheal tube. Anesth Analg 1994; 78: 746–8Brull, SJ Wiklund, R Ferris, C Connelly, NR Ehrenwerth, J Silverman, DG
Greer JR, Smith SP, Strang T: A comparison of tracheal tube tip designs on the passage of an endotracheal tube during oral fiberoptic intubation. A nesthesiology 2001; 94: 729–31Greer, JR Smith, SP Strang, T
Kristensen MS, Moller J: Airway management behaviour, experience and knowledge among Danish anaesthesiologists: Room for improvement. Acta Anaesthesiol Scand 2001; 45: 1181–5Kristensen, MS Moller, J
Fig. 1. The tubes were initially introduced oriented in the “natural” way, meaning with the concavity facing downward toward the lower teeth, tongue, and epiglottis. In this position, the bevel of the standard tube (S  ) is facing the left side of the patient. The Parker Flex-Tip (PFT  ) tube has a symmetrical bevel that faces toward the convex side of the tube.
Fig. 1. The tubes were initially introduced oriented in the “natural” way, meaning with the concavity facing downward toward the lower teeth, tongue, and epiglottis. In this position, the bevel of the standard tube (S 
	) is facing the left side of the patient. The Parker Flex-Tip (PFT 
	) tube has a symmetrical bevel that faces toward the convex side of the tube.
Fig. 1. The tubes were initially introduced oriented in the “natural” way, meaning with the concavity facing downward toward the lower teeth, tongue, and epiglottis. In this position, the bevel of the standard tube (S  ) is facing the left side of the patient. The Parker Flex-Tip (PFT  ) tube has a symmetrical bevel that faces toward the convex side of the tube.
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