We thank very much Xue et al. , for their interesting letter concerning our recently published article in Anesthesiology.1The remarks and questions are important and need some clarifications. Concerning the patients with Cormack and Lehane class I or II, it is right that most often these patients are, and were in our series, easy to intubate. But sometimes, as outlined by Xue et al ., the ease of direct laryngoscopy is not synonymous with ease of tracheal intubation. We encountered a difficult intubation in only 15 patients without any specific causes for their initial intubation failure.

Concerning the use of a stylet, our algorithm did not require the use of this device. We think that the gum elastic bougie (GEB) is more efficient and less traumatic than a stylet. We do not totally agree with Xue et al.  that when the speed of tracheal intubation is important, a stylet should always be used. To our knowledge, no high-evidence-level studies support this statement. In the few studies that compared the stylet to the GEB, the GEB was more efficient and allowed intubation with a shorter time than did the stylet in difficult intubations.2,3 

It is right that GEB is classically indicated only when the Cormack and Lehane class of laryngeal view is less than IV. However, we have already reported the potential interest of using GEB in patients with Cormack and Lehane class IV with a high intubation success rate.4 

In our study, we used the reusable form of intubating Laryngeal Mask Airway (LMA) Fastrach™ (Laryngeal Mask Company Limited, San Diego, CA), not the intubating LMA CTrach™. We agree with Xue et al.  that the intubating LMA CTrach™ is an excellent device and could have been used in our algorithm as a substitute for the intubating LMA Fastrach™. However, it has been reported that intubation through the intubating LMA CTrach™ needs more time than does intubation using the intubating LMA Fastrach™.5Moreover, the cost effectiveness of the intubating LMA CTrach™ is questionable when compared with that of the intubating LMA Fastrach™.5 

*Hôpital Henri Mondor, Créteil, France. xavier.combes@hmn.aphp.fr

Combes X, Jabre P, Margenet A, Merle JC, Leroux B, Dru M, Lecarpentier E, Dhonneur G: Unanticipated difficult airway management in the prehospital emergency setting: Prospective validation of an algorithm. Anesthesiology 2011; 114:105–10
Noguchi T, Koga K, Shiga Y, Shigematsu A: The gum elastic bougie eases tracheal intubation while applying cricoid pressure compared to a stylet. Can J Anaesth 2003; 50:712–7
Gataure PS, Vaughan RS, Latto IP: Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet. Anaesthesia 1996; 51:35–8
Combes X, Dumerat M, Dhonneur G: Emergency gum elastic bougie-assisted tracheal intubation in four patients with upper airway distortion. Can J Anaesth 2004; 51:1022–4
Liu EH, Goy RW, Lim Y, Chen FG: Success of tracheal intubation with intubating laryngeal mask airways: A randomized trial of the LMA Fastrach™ and LMA CTrach™. Anesthesiology 2008; 108:621–6