2025/09/28 by Ronan Hanratty, Ben Dallyn, Jan Hansel +1 · 1 voice
Medicine · #Airway Management and Intubation Techniques #Head and Neck Surgical Oncology #Tracheal and airway disorders
paper · pdf · doi:10.1111/anae.70001
openalex publication_date 2025/09/28 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/15
We welcome the correspondence from Professor Sorbello [1], which raises several interesting technical points in response to our article [2]. We acknowledge the versatility that a bougie offers when navigating an airway in a crowded mouth or restricted hypopharynx. Indeed, the popularity of bougies as airway introducers is highlighted in a study of default videolaryngoscopy where a bougie was used in 26% of cases and a stylet in 10% [3]; notably, when intubating the trachea with a hyperangulated blade, a bougie was used in 25% and a stylet in 75% of cases. We agree that the smaller diameter of a bougie may provide a more favourable initial view during videolaryngoscopy than introducing the tracheal tube directly on a stylet. However, use of a bougie still requires the tracheal tube to be railroaded over the bougie, which may then similarly obscure the view and may be complicated by trauma from advancing the bougie, hold-up during railroading and even bougie displacement leading to unnoticed oesophageal intubation. To reduce visual obstruction with or without a bougie, we recommend using a relatively small tracheal tube (e.g. 6.0–7.0 mm ID) and ensuring the cuff is deflated fully. Professor Sorbello appears to focus on the ‘tracheal tube reaching the laryngeal inlet’ as a definition of ‘success’, but this was not what we studied. Rather, we studied successful tracheal intubation on the first attempt as defined by the ability to place the tracheal tube in the trachea of the manikin and deliver ‘lung ventilation’. We agree that the profile of tracheal introducers that most accurately matched a hyperangulated blade curvature were associated with higher tracheal intubation success rates. Professor Sorbello suggests that the move to videolaryngoscopy has shifted the challenge from obtaining a view of the vocal cords to passing the tracheal tube through them and beyond, and this is a common claim. We believe that, providing good technique is used, this phenomenon should occur very infrequently. A recent publication from our institution reported that the phenomenon of ‘can see, cannot intubate easily’ occurs in around 1 in 10 tracheal intubations with a videolaryngoscope [4]. The phenomenon was associated with clinical and device inexperience, but it was no more frequent with hyperangulated blade videolaryngoscopy than with a standard blade, and likely less common than during direct laryngoscopy. Of note, we did not measure the impact of a second acute angle on passage of the tracheal tube as this problem was not encountered but acknowledge that this may occur in clinical practice elsewhere. We suggest the problems of both tracheal tube delivery to the glottis and passage along the trachea are mitigated by optimising the position of the patient [5]; selection of an appropriately small tracheal tube; using an effective intubation technique; and having appropriate training and experience.