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Reply to

the ‘alligator mouth’ or ‘reflective intubation’ manoeuvre? Describing and modifying the same useful technique for difficult intubation

Biro, Peter

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European Journal of Anaesthesiology: January 2016 - Volume 33 - Issue 1 - p 66
doi: 10.1097/EJA.0000000000000331
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Ozyilkan et al. (pp. 65–66) have commented on our article entitled ‘The reflective intubation manoeuvre increases success rate in moderately difficult direct laryngoscopy: a prospective case-control study’.1 They kindly acknowledged our article as a useful contribution in the domain of overcoming unexpected difficulties during direct laryngoscopy and intubation [Ozyilkan et al. (pp. 65–66)]. However, they raised some critical points regarding reflective intubation, and therefore we would like to comment on their remarks and somewhat rectify their views. A first critique is that our terminology (reflective intubation) is a little far from describing the technique exactly, and may be open to misinterpretation. We reply that the term has been extensively explained in the original article by envisioning the ends of the tube to approach each other similar to a reflection in a mirror, which gave rise to the name of the procedure. The intention of the name is mainly to distinguish the method from other procedural techniques and less to describe details of the technique itself. Another comment by Ozyilkan et al. (pp. 65–66) is that the ‘practitioner had to use a significant pressure on the body of the tube to generate a proper curve to facilitate the insertion. Also pressing the tube to teeth and/or gum as a fulcrum was inappropriate for patients with loose teeth or fragile gums such as the elderly. In our opinion, and according to our vast experience with reflective intubation, when the method is applied correctly, there is no necessity to exert ‘significant pressure’, neither on the tube shaft nor on the upper dental row. We explicitly stated in our article that the pressure must be in any case ‘gentle’ requiring only very limited force sufficient to bend the tube shaft.1 More pressure is certainly not necessary and when gentle pressure does not yield the desired effect of appropriate bending, then the method has to be recognised as unsuccessful and abandoned in favour of a more promising alternative.

After having expressed their doubts about the suitability of reflective intubation, the authors switch to their ‘animalistic’ alternative which they call ‘alligator mouth’, a term which in our opinion reflects its characteristics to an even lesser extent than ours. However, the issue is not the name; what counts is the necessity to retract the already introduced tube out of the oral cavity in order to bend it to the shape of a biting alligator. In addition to the fact that there is no guarantee that the tube will keep its shape once it is forwarded into the oropharynx, this manoeuvre has the fundamental disadvantage of needing a second, or more, attempts at intubation. This loses the main advantage of reflective intubation, which is that this auxiliary move can be performed within the frame of the first intubation process. We consider the avoidance of multiple attempts at laryngoscopy and intubation as an important benefit for the patient. Therefore, any technique that requires multiple approaches, including the peculiar involvement of water-dwelling reptiles, is seen as less suitable.

Acknowledgements related to this article

Assistance with the letter: none.

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Conflicts of interest: none.


1. Biro P, Ruetzler K. The reflective intubation manoeuvre increases success rate in moderately difficult direct laryngoscopy: a prospective case-control study. Eur J Anaesthesiol 2015; 32:406–410.
© 2016 European Society of Anaesthesiology