We sincerely thank Xue et al.1 for the careful reading of our article2 and their valuable comments. We recall that the primary purposes of this study were the feasibility of awake fibreoptic intubation and patient tolerability of this type of procedure.
On the first point, we fully agree with the reservation of Xue et al. about hydroxyzine premedication which is no longer routinely used in our patients. As for midazolam, it had not seemed appropriate at the time of the study because of its deleterious effects on airway tone and on patients’ memory of the intubation (patients’ tolerability of the procedure was one of the points tested in the study). Because of the high variability of responses among patients and the depressant effect of the drug on the tone of airway muscles, we still reject its use for predicted difficult intubation in awake patients.
Regarding the second point, we have also abandoned the routine use of atropine and scopolamine given as antisialagogue agents. However, most of the patients actually suffer from a lack of secretions due to previous cancer treatments (surgery, radiation therapy) and glycopyrrolate is not available for clinical use in France. Administration of atropine or scopolamine is sometimes required to diminish secretions and facilitate intubation.
Information on the duration of upper airway preparation would certainly be helpful, but this point did not seem essential to us, as this preparation step can be performed outside the operating room, thereby avoiding delays in the turnover of patients. However, we agree that the quality of airway preparation is essential to the success of the procedure.
Finally, we confirm that independent investigators evaluated patients’ perception and recall of the procedure. In total, 84–91% of our patients rated their global perception of awake intubation as good, even when the procedure did not meet all the criteria for success. We believe that this point should be distinguished from anaesthesia awareness, as this occurs when a patient under general anaesthesia becomes aware of events during invasive surgery, but without discomfort or pain. Indeed, patients in our study were fully informed of the procedure and of their potential reactions. They were in constant vocal contact with the operator and provided clear answers to the operator's questions until the end of the intubation and induction of general anaesthesia by propofol. They were fully aware beforehand of the necessity to maintain spontaneous breathing, even if the procedure carried a risk of transient discomfort. Almost all patients were willing to undergo the same procedure in the future if medically indicated.
1. Xue F-S, Liu H-P, Liao X, Wang Q, Yuan Y-J, Liu J-H. Awake intubation performed with the Bonfils intubating fibrescope in patients with a difficult airways. Eur J Anaesthesiol
2. Mazères JE, Lefranc A, Cropet C, et al. Evaluation of the Bonfils intubating fibrescope for predicted difficult intubation in awake patients with ear, nose and throat cancer. Eur J Anaesthesiol