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Correspondence

The orotracheal tube dance

Schoettker, Patrick

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European Journal of Anaesthesiology (EJA): June 2015 - Volume 32 - Issue 6 - p 443-444
doi: 10.1097/EJA.0000000000000134

Editor,

The use of malleable stylets or bougies to assist orotracheal intubation is an integral part of difficult airway algorithms.1 Their use in routine intubation might be on the rise with the recent development of videolaryngoscopy.2 Although high-resolution micro-cameras have been inserted in specially designed blades allowing visualisation of the laryngeal inlet, manoeuvrability of the distal end of the tube is necessary to allow it to advance beyond the glottis opening into the trachea.

Recently, a dynamic ‘two-curve’ theory about laryngoscopy and airway passage has been described,3 associating the oropharyngeal axes with the pharyngeal-laryngeal vestibule axes.

By combining the stiffness of a preformed rigid stylet with proper movements of orotracheal tube (rotation) and stylet (withdrawal), a three-dimensional dancing motion of the distal end of the tube can be obtained (Figs 1 and 2). A two-panel picture of the main manoeuvres necessary to obtain tube dance is shown (Figs 1 and 2). A videolink of the dynamic tube movement (Mallinckrodt Hi-Contour Oral/Nasal Tracheal Tube Cuffed ID 7.5; Covidien, Hazelwood, Missouri, USA) obtained by properly coupling tube rotation, stylet stiffness and removal is provided (Supplemental Digital Content 1, http://links.lww.com/EJA/A55). The stylet must be lubricated and shaped ‘straight-to-cuff’ with a bend angle at the extremity not exceeding 35°. Its withdrawal will move the tip of the tube anteriorly while tube rotation will lead to extremity ‘dancing’.

Fig. 1
Fig. 1:
Rotate tube while withdrawing stylet.
Fig. 2
Fig. 2:
A three dimensional tube dance is obtained.

These conjoint manoeuvres of dynamic stylet intubation under videolaryngoscopic view can be extremely helpful in tracheal intubation owing to difficulty in tube advancing beyond the glottis opening, modified anatomy or oropharyngeal tumours.

Acknowledgements relating to this article

Assistance with the letter: none.

Financial support and sponsorship: none.

Conflicts of interest: none.

References

1. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59:675–694.
2. Rai MR. The humble bougie…forty years and still counting? Anaesthesia 2014; 69:199–203.
3. Greenland KB, Edwards MJ, Hutton NJ, et al. Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications. Br J Anaesth 2010; 105:683–690.
© 2015 European Society of Anaesthesiology