We appreciate Drs Wright and Sudan's interest [1] in the consensus guidelines for preventing unrecognised oesophageal intubation [2] and agree with the principle of ‘precision intubation’, a process that should be deliberate, careful and appropriately paced. As such, we support their view that tracheal tube cuff inflation should be performed under vision, and removal of the videolaryngoscope blade, following passage of the tracheal tube, should not be rushed. However, we feel that the guidelines' existing recommendation that “following intubation, the ability to see the tube between the cords and anterior to the arytenoids should be assessed prior to withdrawal of the laryngoscope blade” [2] achieves the proposed benefits of their “total videoscopic tracheal intubation” technique without the potential for unintended adverse consequences.

The suggestion by Wright and Sudan of total videoscopic tracheal intubation entails leaving the laryngoscope blade in position until sustained exhaled carbon dioxide is confirmed. As this requires at least seven breaths, the prolonged laryngoscopy may result in an extended stress response and an increased risk of airway trauma. Given most tracheal tubes are correctly located, the threat of these complications may outweigh any benefit. It also has the potential to make ergonomics awkward and impedes the airway operator managing other aspects of the induction process during this period. Conversely, once initial carbon dioxide return is observed, the guideline process would allow securing of the tracheal tube, confirmation of anaesthetic delivery, etc. while the first seven breaths are delivered, followed by a two-person check for sustained exhaled carbon dioxide. This process has been shown to be practical in a clinical setting [3].

Of greater concern is their suggestion that this technique could reduce the need to remove the tracheal tube. No matter how reassuring the view at laryngoscopy, the absence of sustained exhaled carbon dioxide mandates removal of the tracheal tube, unless it is considered dangerous to do so [2]. Laryngoscopy in isolation cannot be used to exclude oesophageal intubation. Even in the rare circumstance where default removal of the tracheal tube is considered dangerous, repeat laryngoscopy is recommended only to more rapidly identify oesophageal intubation, while valid alternative techniques of flexible bronchoscopy, ultrasound or use of an oesophageal detector device are required to exclude it [2]. Thus, repeat (or in this case sustained) laryngoscopy can only lower the threshold for removing the tracheal tube, not raise it. Leaving the tracheal tube in despite the absence of sustained exhaled carbon dioxide, based on continuous visualisation of the larynx, represents a potential fixation error that could increase the risk of unrecognised oesophageal intubation [4].

Optimal airway management should be safe and effective, while being as ergonomically straightforward, simple and elegant as possible. We feel that that the existing guideline recommendations achieve this.

我们感谢 Wright 博士和 Sudan 博士对预防未被发现的食管插管的共识指南 [1] 的兴趣 [2]，并同意“精确插管”的原则，这一过程应该是深思熟虑、谨慎和适当节奏的。因此，我们支持他们的观点，即气管插管套囊充气应在视觉下进行，并且在气管插管通过后不应急于移除电子喉镜刀片。然而，我们认为指南的现有建议，即“插管后，应在撤出 喉镜刀片之前评估看到脊髓之间和杓状软骨前部的管子的能力 ”[2]，实现了他们的“全视频镜气管插管”技术所提出的好处，而不会产生意想不到的不良后果。

Wright 和 Sudan 建议进行全视频镜气管插管，需要将喉镜刀片留在原位，直到确认持续呼出的二氧化碳。由于这需要至少 7 次呼吸，因此长时间的喉镜检查可能会导致延长的压力反应和气道创伤的风险增加。鉴于大多数气管插管的位置都正确，这些并发症的威胁可能超过任何好处。它还有可能使人体工程学变得尴尬，并阻碍气道操作者在此期间管理诱导过程的其他方面。相反，一旦观察到最初的二氧化碳回流，指南过程将允许在前 7 次呼吸时固定气管插管、确认麻醉剂输送等，然后由两人检查持续呼出的二氧化碳。这个过程已被证明在临床环境中是可行的 [3]。

更令人担忧的是，他们认为这种技术可以减少移除气管插管的需要。无论喉镜检查的视野多么令人放心，如果没有持续呼出的二氧化碳，就必须拔除气管插管，除非认为这样做很危险[2]。单独使用喉镜检查不能用于排除食管插管。即使在极少数情况下，默认拔除气管插管被认为是危险的，也建议重复进行喉镜检查，以便更快地识别食管插管，而需要有效的替代技术，如软式支气管镜检查、超声或使用食管探测器装置来排除它[2]。因此，重复（或在这种情况下持续）喉镜检查只能降低移除气管插管的阈值，而不是提高它。根据喉部的持续观察，即使没有持续呼出的二氧化碳，仍将气管插管留在管内，这代表潜在的固定错误，可能会增加未识别的食管插管的风险[4]。

最佳气道管理应该是安全有效的，同时尽可能符合人体工程学的简单、简单和优雅。我们认为现有的指南建议实现了这一点。