We thank the authors of both letters for their thought-provoking comments. In the first letter, Dr. Mahajan et al
. refer to the incidence of nasopharyngeal bleeding after native tubes in our study1
(56%) and the incidence after warmed tubes and a vasoconstrictor in the study by Elwood et al
(29%). Although these were both “control” groups, the two treatments have no common basis for comparison. Considering the incidence of bleeding associated with warmed tubes in the two studies,1,2
Dr. Mahajan et al
. posit that the 0.5-mm-larger tube diameter in our study contributed to the greater incidence of bleeding. This is a possibility that we did not test. Whether the larger tube diameters in our study contributed to the incidence of bleeding with native and warm tubes is a moot point because the incidence of bleeding with a larger diameter tube telescoped into a soft rubber catheter seems to be trivial (5%).1
Further direct comparisons between the results of the two studies should be limited because we did not test the effect of oxymetazoline in our study. Although the larger-diameter uncuffed tubes may have contributed to the incidence of bleeding in our study, this was a compromise rooted in our other concern to minimize the magnitude of the endotracheal tube leak. The authors correctly point out that we did not report complications from nasotracheal intubation that occurred in the postanesthesia care unit and thereafter. We can state categorically, though, that whereas surrogate markers for complications may have occurred, neither ear, nose, and throat consultation nor admission to or delayed discharge from the hospital occurred as a result of nasopharyngeal bleeding.
Dr. Wu also questions the sizes of the tubes that we used and the magnitude of the endotracheal tube leak. We did not change any of the tubes because the tracheal leak was too large. This is not to suggest that such a situation cannot occur. However, during dental surgery, we minimize the clinical impact of a small endotracheal tube leak by maintaining spontaneous ventilation and by packing the throat with gauze. There is no evidence that the size of the larynx in children in the United States varies geographically. Dr. Wu describes a modification to the proximal end of a cuffed straight nasal tube to facilitate its use in dental surgery, which is analogous to using the old-fashioned metal “nasal” connectors. However, we urge caution when considering the use of “homemade” modifications to airway devices that have not been tested under rigorous conditions to identify the risks of failure and disconnect during anesthesia.
Stacey Watt, M.D.
Jerrold Lerman, M.D., F.R.C.P.C., F.A.N.Z.C.A.*
*Women and Children’s Hospital of Buffalo, State University of New York at Buffalo, Buffalo, New York. email@example.com
1. Watt S, Pickhardt D, Lerman J, Armstrong J, Creighton PR, Feldman L: Telescoping tracheal tubes into catheters minimizes epistaxis during nasotracheal intubation in children. Anesthesiology 2007; 106:238–42
2. Elwood T, Stillions DM, Woo DW, Bradford HM, Ramamoorthy C: Nasotracheal intubation: A randomized trial of two methods. Anesthesiology 2002; 96:51–3
© 2007 American Society of Anesthesiologists, Inc.