Johnson et al.’s  1pictorial documentation of the structures that obstruct the passage of an endotracheal tube during fiberoptic intubation is brilliant and once again proves the usefulness of a 90° counterclockwise rotation of the endotracheal tube to facilitate advancement.2 

Unfortunately, they have, like some authors before them, failed to acknowledge the contribution of Dr. Cossham, who first described this technique to facilitate the passage of an endotracheal tube over a gum elastic bougie.3When passage of an endotracheal tube over a fiberscope is difficult, most clinicians had, hoping to bypass the obstruction, retried while or after twisting the tube left or right—a somewhat haphazard maneuver also mentioned by Ovassapian et al.  4It was Dr. Cossham, however, who actually clearly illustrated the technique. Whether over a gum elastic bougie or over a flexible bronchoscope, his technique is elegant and proven,5and the principles are the same. It is such a useful “trick” that we believe that the first attempt to advance an endotracheal tube over a flexible bronchoscope should always be made with it already turned counterclockwise by 90°.6Our experience is that the success rate exceeds 90% with only one attempt, thus saving time and reducing the risk of upper airway trauma and unpleasantness for the patient.

*The Chinese University of Hong Kong, Shatin, NT, Hong Kong Special Administrative Region, Peoples’ Republic of China.

Johnson DM, From AM, Smith RB, From RP, Maktabi MA: Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation. Anesthesiology 2005; 102:910–4
Kristensen MS: The Parker Flex-Tip Tube versus  a standard tube for fiberoptic orotracheal intubation: A randomized double-blind study. Anesthesiology 2003; 98:354–8
Cossham PS. Difficult intubation (letter). Br J Anaesth 1985; 57:239
Ovassapian A, Yelich SJ, Dykes MH, Edward EB: Fiberoptic nasotracheal intubation: Incidence and causes of failure. Anesth Analg 1983; 62:692–5
Dogra S, Falconer R, Latto IP: Successful difficult intubation: Tracheal tube placement over a gum-elastic bougie. Anaesthesia 1990; 45:774–6
Ho AMH, Chung DC, Karmakar MK: Is the Parker Flex-Tip Tube really superior to the standard tube for fiberoptic orotracheal intubation? (letter). Anesthesiology 2003; 99:1236