Dear Sir,
We are writing in regards to a case series in the October-December issue titled “Gum elastic bougie as a guide in nasotracheal intubation: A novel technique.” The authors described five cases in which difficult passage of a nasotracheal tube was overcome by the use of a nasally placed bougie as part of a Seldinger-based technique. Bhat Pai et al. correctly point out that the use of an airway bougie can facilitate nasotracheal intubation in a variety of difficult clinical scenarios. The suggestion that this is a novel technique, though, is of question.
As early as 1997, Cossham described the routine use of bougies in nasotracheal intubation.[1] In 2006, Arora et al. presented a series of three pediatric cases in which a gum-elastic bougie was used to facilitate blind nasotracheal intubation in children.[2] Also in 2006, Morimoto et al. described the use of a curve-tipped suction catheter as a guide for nasotracheal intubation, showing a significant decrease in nasal bleeding with the technique.[3] In 2010, Arisaka et al. described the successful use of a similar technique in 16 patients who had failed nasotracheal intubation through conventional methods.[4] In 2008 and 2014, Inoue and Kitano, respectively, described the use of gum-elastic bougies as guides in cases of challenging nasotracheal intubation.[5,6] In 2013, Staar et al. studied the use of modified Magill forceps for glottic navigation of nasally placed bougies.[7] In 2015, Abrons et al. presented a case series in which pediatric bougies, guided by nasal trumpets, were utilized as guides for successful nasal intubation under challenging conditions.[8] In 2017, Abrons et al. prospectively studied this technique of nasotracheal intubation over a bougie passed through a nasopharyngeal airway in 257 patients, showing a significant decrease in both the incidence and severity of nasal trauma, with less need for Magill forceps, than with the conventional technique of blind nasal passage and external tube manipulation.[9]
The above literature outlines the increasing knowledge of, and experience with, nasotracheal intubation over bougies. With this evidence-based foundation, the goal of achieving atraumatic nasal intubation inches closer. While the contribution of Bhat Pai et al. to the lexicon is appreciated, the above-cited works clearly show that the suggestion of novelty is questionable.
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References
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