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LETTERS TO EDITOR
Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 556-557

The novel “FIT” of endobronchial intubation: Whimsical contention or factitious science?


Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
Dr. Akhil Kumar
B-6/11A, Shyam Vihar Phase 2, Dinpur, Najafgarh - 110 043, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.SJA_165_20

Rights and Permissions
Date of Submission26-Feb-2020
Date of Acceptance26-Feb-2020
Date of Web Publication24-Sep-2020
 


How to cite this article:
Kumar A, Dutta A, Sharma S, Sood J. The novel “FIT” of endobronchial intubation: Whimsical contention or factitious science?. Saudi J Anaesth 2020;14:556-7

How to cite this URL:
Kumar A, Dutta A, Sharma S, Sood J. The novel “FIT” of endobronchial intubation: Whimsical contention or factitious science?. Saudi J Anaesth [serial online] 2020 [cited 2020 Nov 30];14:556-7. Available from: https://www.saudija.org/text.asp?2020/14/4/556/295997



Sir,

We read with interest the article by Anand et al.[1] on fibreoptic in tracheal lumen (FIT) technique detailing accurate positioning of a double-lumen tube (DLT) into the intended bronchus. However, their fictitious proclamation about the novelty (already published in 1999)[2] and unscientific propositions and conclusions (safer, faster, and definitive) sounds a bit trifling.

Incidence of successful endobronchial intubation of the intended bronchus with a DLT, aided by conventionally accepted manipulations, using the standard and widely accepted blind technique as reported in various studies is 94.5%,[3] 93.75%,[4] and 99.29%,[5] respectively. As evident, in the majority of the cases, correct placement of a DLT can be achieved by the traditional blind methods and furthermore, FOB or the expertise to handle it might not be readily available. In addition, FOB-guided placement is certainly likely to fail, in the settings of exudative lung pathology (bronchorrhea or hemoptysis), as the suction channel of the small bronchoscope used in DLTs has limited capacity to remove secretions, making visualization of important anatomical landmarks relatively difficult. Boucek et al.,[4] in a couple of patients, when unable to place a DLT with the FOB guidance due to severe bronchorrhea, had reverted to conventional blind technique to succeed.

The idea of placing a FOB in the tracheal lumen is ill-conceived and offers no assistance in repositioning a misplaced DLT. It is surprising that the authors had a 100% successful placement of the DLT which is in conflict with the published literature.[3],[4],[5] It would be interesting to learn what strategy would the authors adopt to correct a malpositioned DLT with the FOB in the tracheal lumen. Possibly any attempts to rotate the DLT to guide in the desired bronchus (option available with the authors), will prove to be futile, due to inability to transmit the rotational force applied at the proximal end to the entire length of the DLT and effect a rotation. The accepted norm to correctly position a difficult-to-place DLT is by passing the FOB successfully into the intended bronchus through the bronchial lumen (not tracheal) and railroading the DLT over it.[3],[4]

Per se, visual access to glottis inlet does not get impeded during the placement of DLT inside the trachea (thinner bronchial segment, two curves), if done correctly; secondly, the use of FOB, a delicate and costly aid, is required for ensuring adequacy of both tracheal placement (assessing through tracheal lumen) and lobar ventilation (evaluating through the bronchial lumen for final tip position); thirdly, the authors did not mention the purpose and scientific basis of using FOB in the tracheal lumen to ground adequacy of bronchial tube positioning; and finally, they failed to convey whether the patient cohort (n = 34) which they included in the letter involved “consecutive” or “convenience” sample.

To conclude, labelling a novelty makeover to a routinely employed FOB guidance of DLT placement and positioning without scientific basis violates ethical principles of Beneficence (no help to the “vulnerable” thoracic surgery patients), Non-maleficence (silent on bronchial tip positioning), and Justice (would promote misuse of a precious FOB resource).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Anand LK, Singh M, Singh J, Kapoor D. 'Fibreoptic in tracheal lumen' (FIT) technique: A novel real-time double-lumen tube placement technique with fibreoptic bronchoscope. Saudi J Anaesth 2019;13:388-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Cheong KF, Koh KF. Placement of left-sided double lumen endobronchial tubes: Comparison of clinical and fibreoptic-guided placement. Br J Anaesth 1999;82:920-1.  Back to cited text no. 2
    
3.
Brodsky JB, Lemmens HJ. Left double-lumen tubes: Clinical experience with 1,170 patients. J Cardiothorac Vasc Anesth 2003;17:289-98.  Back to cited text no. 3
    
4.
Boucek CD, Landreneau R, Freeman JA, Strollo D, Bircher NG. A comparison of techniques for placement of double-lumen endobronchial tubes. J Clin Anesth 1998;10:557-60.  Back to cited text no. 4
    
5.
Seo JH, Bae JY, Kim HJ, Hong DM, Jeon Y, Bahk JH. Misplacement of left-sided double-lumen tubes into the right mainstem bronchus: Incidence, risk factors and blind repositioning techniques. BMC Anesthesiol 2015;15:157.  Back to cited text no. 5
    




 

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