To the Editor: 

We read with great interest the article of Lee JJ et al.  that describes two complications of tracheal intubation in a neonate.1 

We believe, however, that these two complications could have been avoided if the following precautions and techniques were used. (1) Tracheal intubation was achieved after three esophageal intubations. It was not mentioned if the esophageal intubation was done because of difficult airway or involved an endoscopist not experienced in neonatal intubation. If the case was difficult airway and the glottis was not seen, a supraglottic airway such as an Air-Q™#1.0 (Clearwater, FL) could have been immediately inserted to provide ventilation. If an endotracheal intubation is mandatory, a fiberoptic-guided tracheal intubation through the Air-Q™ can be performed.2(2) Proper placement of the endotracheal tube (ETT) to 8 cm distance at the lips could have avoided the right endobronchial intubation if the ETT was pulled to 8 cm at the lips and not left at 11 cm while starting positive pressure ventilation. (3) Proper placement of the ETT can be confirmed by: bilateral breath sounds, capnogrpahy, and insertion of a lubricated ultra-thin fiberoptic scope through the ETT (Olympus LF-P [Center Valley, PA] with a 2.2 mm external diameter) and confirming placement of the ETT (1.0–1.5 cm) above the carina in this case. If these precautions were followed, the endobronchial intubation and unnecessary surgery for gastric perforation from esophageal intubation could have been avoided. The authors have currently concluded that specialized training and experience are needed for neonatal airway management. However, use of a supraglottic airway as described above improves the likelihood of successful airway management by less experienced clinicians.

Lee JJ, Ryu BY, Ji Su Jang JS, Hwang SM: Two complications of tracheal intubation in a neonate: gastric perforation and lung collapse. ANESTHESIOLOGY 2011; 115:858
Jagannathan N, Roth AG, Sohn LE, Pak TY, Amin S, Suresh S: The new air-Q intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: A case series. Paediatr Anaesth 2009; 19:618–22