Authors’ Reply to Letter to the Editor “Comparing Sedation Regimens for Awake Fiberoptic Intubation”

There are no conflicts of interest. midazolam versus Sufentanil‑midazolam for awake fiberoptic nasotracheal intubation: A randomized double‑blind study. effective dose of remifentanil for awake laryngoscopy and intubation. airway topical anesthesia in patients with a difficult airway: A randomized, double‑blind comparison of 2% and 4% lidocaine. Comparison of dexmedetomidine and sufentanil for conscious sedation in patients undergoing awake fibreoptic nasotracheal intubation: A prospective, randomised and controlled clinical trial. Dexmedetomidine versus remifentanil sedation during awake fiberoptic nasotracheal intubation: A double‑blinded randomized controlled trial. We appreciate Prof. Xue et al. for their thoughtful comments on our study. [1] We agree with them that history of smoking and respiratory comorbidities can increase airway reactivity to airway irritation, resulting in an increased severity of cough. In our study, patients with a history of smoking and respiratory comorbidities were excluded and the demographic data of patients were comparable between the groups. Furthermore, two senior anesthetists actualizing our study had equal proficiency with the use of fiberoscope and had performed more than 50 fiberoptic intubation for difficult airway management before this study. To ensure the consistency and repeatability of measurements, the procedure of awake fiberoptic nasotracheal intubation was normalized by video training and the test tools were illustrated for all participants before the study. In addition, we know that both patient's head position and airway clearance procedure can affect ease of fiberoscopy and tracheal tube placement. In our study, the patient's head was placed in the sniffing position with a 6 cm‑high firm pillow under the occiput and the jaw‑thrust was performed for the airway clearance. As to the airway topical anesthesia, we completely agree with Xue et al. that a reasonable waiting period after each lidocaine spray helps ensure topical anesthetic to go into effect and reach peak effect, but spray of lidocaine via the working channel of fiberoscope often does not cover the whole supraglottic and glottic areas, and maybe only covers a small airway area. Therefore, even the contact time of lidocaine with the airway mucosa is enough, it may also not meet the requirement to pass fiberoscope and tracheal tube, as shown in the previous studies. In the previous study by Xue et al., [2] 61.5–73.1% of patients displayed grimacing and coughing responses during awake fiberoptic orotracheal intubation, though the patients received the classic " spray‑as‑you‑go " technique under midazolam and fentanyl sedation. Jiang et al. [3] also showed that the incidence of …