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

Ozyilkan, Nesrin Bozdogan; Cok, Oya Yalcin; Aribogan, Anis

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European Journal of Anaesthesiology: January 2016 - Volume 33 - Issue 1 - p 65
doi: 10.1097/EJA.0000000000000332
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We read with great interest the article by Biro and Ruetzler1 entitled ‘The reflective intubation manoeuvre increases success rate in moderately difficult direct laryngoscopy: a prospective case-control study’. In this article, the authors report on a high success rate during tracheal intubation of patients with limited glottic visibility. Airway management has always been a critical part of anaesthetic practice and difficult airway management continues to be a challenge. New trends in the management of the difficult airway are based on developing novel imaging equipment and techniques rather than promoting blind manoeuvres. However, exercising manual airway skills is still key for successful and safe management when expected or unexpected difficulty is encountered.2,32,3 The capability to deal with a difficult tracheal intubation using anaesthetists’ own skills and circumstances should be improved and techniques such as reported by Biro and Ruetzler1 should be included in the curriculum. Although this article describes a very useful approach, we believe that the terminology ‘reflective intubation’ is a little far from describing the exact technique and open to misinterpretation. When we practiced this technique in our patients after having read the article, we realised that it was quite difficult to bend the tube inside the mouth as the practitioner had to use significant pressure on the body of the tube to generate a proper curve to facilitate the insertion. In addition, pressing the tube to both teeth and/or gum as a fulcrum was not appropriate for patients with loose teeth or fragile gums such as in the elderly. In our opinion, if difficult tracheal intubation is unexpectedly encountered, the tracheal tube should be retracted and reshaped by bending and then reintroduced. Bending the tube outside the mouth and holding it firmly may avoid injury caused by the tube while manipulating it during insertion. In addition, when bent outside the mouth, prior to introducing during laryngoscopy, the tracheal tube looks like an ‘alligator mouth’; it can be opened and closed through the appropriate changing of the angle of the tip (Fig. 1). We suggest that this modification and description may increase the comprehensibility and applicability of this valuable manual technique. It may take its place in clinical practitioners’ armamentarium as another ‘rescue’ during difficult tracheal intubation before algorithm-guided preparations are made.

Fig. 1
Fig. 1:
The tube like an ‘alligator mouth’: (a) ‘open’ and (b) ‘closed’ to change the angle of the tip.

Acknowledgements related to this article

Assistance with the letter: none.

Financial support and sponsorship: none.

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.
2. Yamamoto K, Tsubokawa T, Ohmura S, et al. Left-molar approach improves the laryngeal view in patients with difficult laryngoscopy. Anesthesiology 2000; 92:70–74.
3. Bozdogan N, Sener M, Bilen A, et al. Does left molar approach to laryngoscopy make difficult intubation easier than conventional midline approach? Eur J Anaesthesiol 2008; 25:681–684.
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