We read with great interest the letter from El-Ganzouri and Ads. They made helpful comments on our report.1It is unfortunate that we did not mention why the complications were developed.

The infant at 33-weeks gestation who weighed 2,050 g was delivered at a private hospital. At birth, the baby was dyspneic, and tracheal intubation was attempted by a physician who lacked much experience in neonatal intubation. An endotracheal tube was inserted into the esophagus three times, resulting in marked abdominal distension. Tracheal intubation was successful on the fourth attempt. After 80 min of ventilator care, the baby was tachycardic with an oxygen saturation of 80–90%. He was transferred to our hospital.

I agree that these complications were made more likely by the prior esophageal intubations by a less experienced clinician.

However, all hospitals, especially private hospitals, don't have experts in airway management available at all times.

The main message of our report remains that immediately after intubation, adequate placement and depth of the endotracheal tube should be confirmed using end-tidal carbon dioxide, auscultation, endotracheal tube depth, and chest x-ray.

Lee JJ, Ryu BY, Jang JS, Hwang SM: Two complications of tracheal intubation in a neonate: Gastric perforation and lung collapse. ANESTHESIOLOGY 2011; 115:858