Letters to Editor A rare, potentially hazardous malposition of the nasotracheal tube Sir, I read with interest the brief communication, “A rare potentially hazardous malposition of the nasotracheal tube” by Murali Chakravarthy.[1] I appreciate the authors’ concerns regarding the emphasis of following of standard procedure to avoid errors during fibreoptic bronchoscopy (FOB)-aided intubation However, I am not totally convinced with the author’s way of dealing with this particular case And I have the following points of disagreement and dissatisfaction: Why had regional anaesthesia not been chosen for this patient – it is not mentioned by the author anywhere that regional anaesthesia should have been the first choice of anaesthesia for right hiparthroplasty, in this patient looking for the following points narrated by author: a) Severely obese patient [? Body mass index (BMI) not known] b) H/O obstructuve sleep apnoea (OSA) single years c) H/O chronic smoking [suggestive of possibility of chronic obstructive pulmonary disease (COPD)] d) Mallampatti Class e) Short neck and limited neck mobility f) Severely deviated nasal septum Experts mention that, when feasible, regional anaesthesia (RA) using a catheter to provide continuous anaesthesia is useful in patients with OSA.[2] Moreover, regional analgesia is associated with a low incidence of apnoea and periods of arterial hypoxaemia, making this approach an attractive technique for providing post-operative analgesia in such a patient.[2] The authors have mentioned that as the patient seemed uncomfortable because of the presence of endotracheal tube (ETT), general anaesthesia (GA) was induced, but there is no mention of what was the SPO2 during that time? Also, whether restlessness of the patient was just due to ETT/gradual development of hypoxaemia/ lignocaine toxicity (from repeated topical spray) In case of a really difficult intubation, 434 wherein we are planning for an awake FOBaided ET intubation, induction of full-fledge GA with use of a non-depolarizing muscle relaxant at the very first instance does not seem to be “Standardized Guidelines” in any institute in the Indian scenario Also, if you as a team had decided to induce him, then also the best choice would have been to take the patient deep into sevoflurane anaesthesia only with spontaneous ventilation because awakening of the obese patient is prompter after exposure to sevoflurane than after administration of even Propofol.[3] Moreover, we all know that neuromuscular blocking drugs, characterized by rapid spontaneous recovery, are most often selected in such group of patients.[3] Needless to emphasize, when a muscle relaxant is to be employed in a difficult/potentially difficult airway, succinylcholine appears to be the relaxant of choice, unless contradicted.[3] The authors mention that institutional protocol is to confirm correct ETT portion before commencement of surgery in FOB-guided awake intubation However, in any such difficult case, the protocol must be in proper conformation before induction of full-fledge GA, or else one may encounter catastrophic events The authors mention that repeated FOB revealed the tonsils at and ‘O clock positions at the distal end of ETT, which means that the tip of ETT must be somewhere around the anterior pillar of the tonsils rather than abutting the pharyngeal inlet Also, repeated ETT cuff inflation was mentioned by the authors, but there was no documentation of up to how much cuff pressure was it inflated to seal the oropharynx of this patient? Thus, that too is misleading Last but not the least, whether the coughing was still present while rail roading the ETT over bronchoscope was not mentioned by the authors If the coughing was present, then the tube might have not properly passed between the vocal cords in the very first instance Moreover, the authors mention that attempts to “railroad” ETT over FOB may have resulted in loop formation, which indicates that there was definite difficulty in sliding of tube over the FOB Experts say that if repeated attempts to slide ETT over bronchoscope and into the trachea are unsuccessful/firm resistance is met when tip Indian Journal of Anaesthesia | Vol 56| Issue | Jul-Aug 2012 Letters to Editor of ETT is at the glottic level, the bronchoscope and tube had to be removed as a unit and the procedure began again.[3,4] In such cases, there are chances of “hanging up of Murphy’s tip on the epiglottis”[5,6]/sometimes the bronchoscope may have exited the ETT via Murphy’s eye.[4] Whatsoever be the case, if persistent difficulties are encountered, ventilating and oxygenating the patient, protecting his airway as best as one can and waking him up is the protocol most experts suggest,[7] and the procedure can be begun again.[3] Jitin N Trivedi Consultant Anaesthetist, Ankleshwar, Gujarat, India Address for correspondence: Dr Jitin N Trivedi, Consultant Anesthetist, 12, “Swastik”, Vrundavan Bunglows, Bhd GEB office, Ankleshwar, Gujarat, India E-mail: jitinntrivedi@yahoo.co.in References Chakravarthy M A rare potentially hazardous malposition of the nasotracheal tube Indian J Anaesth 2012;56 Issue –I:81-3 Stoelting RK, Dierdorf SF ‘Anesthesia and Co – Existing Disease’ Fourth ed Harcourt (India) Pvt Ltd.; Philadelphia, 2002 p 441-51 Miller RD 'Anesthesia' 4th ed Philadelphia, US: Churchill Livingstone; 1994 p 1403-33 Nichols KP, Zarnow MA A potential complication of fiberoptic intubation Anesthesiology 1989;70:562-3 Katsnelson T When the endotracheal tube will not pass over the flexible fiberoptic bronchoscope Anesthesiology 1992;76:151-2 Ovassapian A Fiberoptic nasotracheal intubation – incidence and causes of failure Anesth Analg 1983;62:692-5 Ovassapian A Fibreoptic bronchoscope and unexpected failed intubation Can J Anaesth 1999;46:806-10 Access this article online Quick response code Website: www.ijaweb.org DOI: 10.4103/0019-5049.100855 Author Institution Mapping (AIM) Please note that not all the institutions may get mapped due to non-availability of the requisite information in the Google Map For AIM of other issues, please check the Archives/Back Issues page on the journal’s website Indian Journal of Anaesthesia | Vol 56| Issue | Jul-Aug 2012 435 Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use ... Consultant Anesthetist, 12, “Swastik”, Vrundavan Bunglows, Bhd GEB office, Ankleshwar, Gujarat, India E-mail: jitinntrivedi@yahoo.co.in References Chakravarthy M A rare potentially hazardous malposition. .. check the Archives/Back Issues page on the journal’s website Indian Journal of Anaesthesia | Vol 56| Issue | Jul-Aug 2012 435 Copyright of Indian Journal of Anaesthesia is the property of Medknow... When the endotracheal tube will not pass over the flexible fiberoptic bronchoscope Anesthesiology 1992;76:151-2 Ovassapian A Fiberoptic nasotracheal intubation – incidence and causes of failure Anesth