In Reply

I thank Sanfilippo et al. for their constructive comments to my editorial.¹  They state that we have been searching for the holy grail in a single device in vain and that videolaryngoscopes seem far from being the ultimate solution. They suggest that we should regard a combinational use of a laryngoscope and a fiberoptic bronchoscope as a rescue technique, while we await the perfect intubation tool. I agree with their point that the combinational use of intubation devices may be useful, but I have to point out that there is no holy grail, and we cannot find a perfect intubation tool.

In my editorial,¹  I stated that, “[b]ecause the causes of difficult intubation differ among the patients and because there are differences in the efficacy of each intubation device for different causes of difficulty, we need to judge which device is most suitable by identifying the cause of difficult intubation in each patient.” For example, when the mouth opening is severely restricted, only a fiberoptic bronchoscope would be effective, but the fiberscope (even with the combinational use of a laryngoscope) may frequently fail when the airway is severely deformed or when a tumor is obstructing the airway. Therefore, we cannot find a perfect intubation tool.

To judge which device (or combination of devices) is most suitable in each case, we first should obtain accurate knowledge about the efficacy of intubation device(s). For example, Sanfilippo et al., state that, “…video laryngoscopy has the limitation of different axes between visualization and endotracheal tube introduction, which may contribute to the device failure and is not solvable by technology progresses…” This problem has already been solved by some videolaryngoscopes (e.g., the Airtraq or the Pentax Airway Scope), which have grooves on their side, and tracheal tubes can be attached. I have shown that, in adult patients without restricted mouth opening, the incidence of failed tracheal intubation using the Airway Scope was calculated as rare (1 in 2,300 patients).² 

As Sanfilippo et al. imply, the current method of difficult airway management is far from the perfect,³  and thus we still need to carry out clinical studies and acquire accurate up-to-date knowledge and skills about each technique to minimize repeated attempts at tracheal intubation.