To the Editor:

Agarwal et al.1  highlighted the usefulness of three-dimensional reconstruction of computed tomography imaging for the safe management of patients with upper airways stenosis. The authors well described the reasons for performing such advanced imaging and we agree that preoperative work-up of such patients may greatly benefit by the innovative information provided by virtual laryngo-tracheo-bronchoscopy. Yet, virtual laryngo-tracheo-bronchoscopy has great potentialities also in patients with obstructive lesions and can help in planning a safer anesthesiological approach. In fact, it is paramount to consider the risk of airway trauma and consequent bleeding in these patients with expected difficult airways. Therefore, the importance of smooth and uneventful placement of the endotracheal tube cannot be overemphasized.

According to the findings of the virtual laryngo-tracheo-bronchoscopy imaging, the authors decided the appropriate size of the endotracheal tube, which is entirely reasonable; however, it is less clear what they mean by “proper anesthetic induction” and more importantly, which strategy they implemented for positioning the 5.5-cm reinforced endotracheal tube.

The usefulness of a combined two-operator laryngo-bronchoscopic approach for the safe management of such cases has already been reported. Both conventional2,3  and video-laryngoscopes4  have been used in such scenarios to facilitate the introduction of the rigid2  or the flexible bronchoscope,3,4  therefore optimizing the operator view and decreasing the risk of bleeding. Interestingly, a manikin study showed that the combined use of Airtraq® (Prodol Meditec S.A., Vizcaya, Spain) and fiber-optic bronchoscope significantly reduced the time for intubation in difficult laryngoscopy scenarios when compared with the Airtraq® alone.5  It would therefore be useful if the authors could share their technical approach in the management of the airways of such cases.

Competing Interests

The authors declare no competing interests.

References

1.
Agarwal
S
,
Bates
WB
,
Castresana
MR
:
Endoluminal computed tomography: A novel technology for assessment of large airway pathologies.
Anesthesiology
2014
;
121
:
170
2.
Maybauer
MO
,
Maier
S
,
Thierbach
AR
:
[An unexpected difficult intubation. Bonfils rigid fiberscope].
Anaesthesist
2005
;
54
:
35
40
3.
Sgalambro
F
,
Sanfilippo
F
,
Santonocito
C
,
Caltavuturo
C
,
Grillo
C
:
Virtual laryngoscopy and combined laryngoscopic-bronchoscopic approach for safe management of obstructive upper airways lesions.
Br J Anaesth
2014
;
113
:
304
6
4.
Sharma
D
,
Kim
LJ
,
Ghodke
B
:
Successful airway management with combined use of Glidescope videolaryngoscope and fiberoptic bronchoscope in a patient with Cowden syndrome.
Anesthesiology
2010
;
113
:
253
5
5.
Nishikawa
K
,
Hukuoka
E
,
Kawagishi
T
,
Shimodate
Y
,
Yamakage
M
:
Efficacy of the Airtraq® laryngoscope with a fiberoptic bronchoscope compared with that of Airtraq® alone for tracheal intubation: A manikin study.
J Anesth
2011
;
25
:
93
7