In reply: Not which forceps, but whether forceps?
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To the Editor,
We appreciate the keen interest and thoughtful comments by Dr. Turkstra1 on our study2 where we found that using a forceps-guided tube exchanger could be advantageous when using the GlideScope® videolaryngoscope (GVL; Verathon Medical Inc., Bothell, WA, USA) for oral endotracheal tube (ETT) intubation. The reason for an advantage might be the flexibility and pliability of a tube exchanger. Another study of nasotracheal intubation by Lim et al.3 showed that the pliable and flexible nasogastric tube passed preferentially through the lower aspect of the nasal passage with a preformed ETT easily advancing towards the laryngeal inlet. We hypothesized that the flexibility and pliability of a tube exchanger would be effective for nasotracheal intubation using a GVL.4 To apply the same conditions for the two groups, forceps were used in all patients because insertion and removal of the forceps consumed some time.
We performed hundreds of nasal intubations in another study two decades ago5 and are also familiar with a GVL.2 Before study implementation, three operators were trained in nasal intubation using a GVL. As mentioned above, the two different forceps were used in both groups. In the study2 commented on by Dr. Tursktra, the incidence of sore throat was not significantly different between the different groups. Admittedly, a weakness of this study, which compared two different types of forceps, was that the participating anesthesiologists were not blinded to the assigned groups; this could have introduced some bias.
Lastly, Dr. Turkstra cautions against the study’s technique2 of inserting a nasal ETT prior to verifying a good videolaryngoscopic view. We agree with this caution as epistaxis is the most common complication following nasotracheal intubation. Many methods have been used to reduce the incidence and severity of bleeding.3-5 In many studies using a GVL,2,5 glottic exposure was significantly better with the GVL. In this study, only two study subjects had a grade III glottic view, and there were no significant differences between the groups.
In conclusion, using a tube exchanger and vascular forceps offers advantages over the use of Magill forceps and over a GVL for nasotracheal intubation.
Conflicts of interest
This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.