To the Editor:—

Dr. Kristensen 1has concluded that during intubation with the use of a flexible fiberscope, the use of the Parker Flex-Tube results in a significantly lower rate of repositioning and repeated attempts at passing the tube into the trachea, compared to a standard endotracheal tube. We believe it would be more appropriate to conclude that the Parker tube is better only when the standard tube is improperly oriented during passage. Dr. Kristensen reported that once the standard tube was rotated counterclockwise by 90 degrees, its success rate improved to 26 out of 38 attempts. 1This was essentially the same as the success rate (27 out of 38 attempts) of the Parker tube 1and is consistent with our experience with the standard tube. Why not simply start with the standard tube rotated counterclockwise by 90 degrees? The Parker tube requires a higher cuff pressure, 1which, in our opinion, makes it less desirable.

The simple technique of rotating the standard tube counterclockwise by 90 degrees during the first  attempt along a fiberoptic bronchoscope has been our standard practice for years, thanks to a suggestion by Katsnelson et al.  in 1992. 2Eighteen years ago, Cossham 3proposed rotating a standard tube counterclockwise by 90 degrees to facilitate passage along a gum-elastic bougie, and in 1990, Dogra et al.  demonstrated convincingly the usefulness of this technique. 4Granted, this technique may not be widely appreciated, perhaps because the gum-elastic bougie is not used in some parts of the world and the use of fiberoptic bronchoscopy is infrequent. 1As such, Dr. Kristensens'study 1should help to popularize this important “trick.”

Kristensen MS: The Parker Flex-Tip tube versus  a standard tube for fiberoptic orotracheal intubation: A randomized double-blind study. A nesthesiology 2003; 98: 354–8
Katsnelson T, Frost EAM, Farcon E, Goldiner PL: When the endotracheal tube will not pass over the flexible fiberoptic bronchoscope (letter). A nesthesiology 1992; 76: 151–2
Cossham PS: Difficult intubation (letter). Br J Anaesth 1985; 57: 239
Dogra S, Falconer R, Latto IP: Successful difficult intubation: Tracheal tube placement over a gum-elastic bougie. Anaesthesia 1990; 45: 774–6