To the Editor:—
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. firstname.lastname@example.org