An unusual potentially hazardous malposition of naostracheal tube.

Sir,

We thank the authors ………for evincing interest in our article.[1] First of all, we would like to point out that this brief communication was written to highlight the adverse event of the malposition and not to be used as a “gold standard” technique by postgraduates and novices. We quote from the published paper: “This brief publication is being published to highlight the errors that may creep in if the standard procedure is not followed.”

The surgeons anticipated a long duration surgery and blood loss; they requested that general anaesthesia be administered as converting to general anaesthesia (in the event of either wearing off of the regional block or haemodynamic fluctuations) would have proven difficult in the lateral position in an obese patient.

Regarding the question of using the nasal versus the oral route for awake intubation, we would like to state that the nasal route is a physically stable route than the oral route, and it is the preferred route at our institute. However, the operator could choose either route depending on their comfort and experience. It is inappropriate to impose one technique or the other. The author's proposition that regional blocks should always precede awake intubation is untrue. As a matter of fact, we routinely practice awake bronchoscopy either in the operation theatre or in the intensive care unit, without nerve blocks. The use of nerve blocks are also not without risks of intravascular injection, inadequate analgesia, surgical emphysema and injury to the tracheal and surrounding structures.[2-5] Cotter and co-workers have shown that increased body mass index is one of the risk factor for block failure.[5] Postgraduates and beginners should remember that regional block is not panacea.

We conclude our response with the following take home points:

The points highlighted in the case should serve as a warning not to bypass standard recommendations of bronchoscopy-guided intubation. Visualization of carina is an absolutely vital end point, and one should not proceed with anaesthesia without successfully clearing this step

The route (nasal or oral) of intubation using visual guide should be decided by the operator comfort

Regional blocks aiding awake intubation are optional.