A rare potentially hazardous malposition of the nasotracheal tube.

Sir,

We have read with interest the article of Murali Chakravarthi et al. “A rare potentially hazardous malposition of the nasotracheal tube” published in IJA (Vol 56/Issue 1/2012).

We are happy to note that the authors are lucky enough for the successful outcome of the case. Likewise, we would like to address the basis of selection of the type of anaesthesia especially in such a patient posted for hip surgery.

The patient is an obese[1] male and also a chronic and heavy smoker having COPD.[2] He gives H/o Obstructive sleep apnea[3] having to use CPAP mask during nights. His airway assessment shows Mallampati grade 3 with short neck and limited extension of the neck. All the above features favoured difficult intubation. This patient was operated for Hip Arthroplasty under GA.

We are surprised why the authors did not considerregional anaesthesia at all in such a patient. The reason for opting General Anaesthesia instead of regional anaesthesia (which is safe, easy, simple and economical)[45] by the authors could not be justified or substantiated.

Secondly, selection of Nasotracheal intubation over conventional orotracheal intubation in a patient with difficult airway using fibreoptic bronchoscopic technique, that too without completely anaesthetizing the airway. This may be the reason for the severe cough which the patient had while the authors attempted intubation. “Blocks of supralaryngeal nerves bilaterally along with translaryngeal injection of local anaesthetic provides anaesthesia of airway from infraglottic area to the epiglottis” as described by Miller.[6]

Another reason which we feel that the authors could have gone for oral intubation should be to use a large endotracheal tube rather that nasal intubation with small ETT which has high resistance. The authors have not mentioned the resistance encountered by them using the small ETT for that age and weight of the patient.

For all the above reasons, we feel that the authors have violated the basic teachings of anaesthesia regarding the selection of the technique and choice of anaesthesia.