Sir,The recent article of J.-H. Sui et al. 1 comparing the transillumination-assisted orotracheal intubation using the Bonfils fibrescope (Karl Storz, Tuttlingen, Germany) and the lightwand [Trachlight (Laerdal Medical Co., Wappingers Falls, NY, USA)] was of great interest. However, although they have provided valuable information, there are several aspects of this study that have to be clarified. We agree with the authors that this is the first detailed report of the transillumination method of modifying the use of the Bonfils fibrescope, but the results of this study should be extrapolated to the clinical settings with caution. As well reported in literature, 2-7 the best intubation techniques with Bonfils fibrescope (paraglossic or retromolar) involves a continuous endoscopic vision, beginning from introduction into the oral cavity to the visualisation of the vocal cords. Because of its fixed curvature and rigid metallic structure, it could be very dangerous using this device with a blind transoral technique, as proved by the complications that occurred in this study (sore throat 14% and hoarseness 8.7%) 1 and the absence of these when using it correctly. 3,5,7 Furthermore, the brightness of its light source is poorer than that of Trachlight, as well reported by the authors. 1 Moreover, the longer intubation times with Bonfils fibrescope compared with Trachlight would be due to an improper use of the device; a first blind oral introduction was followed by an endoscopic view of the operator through the eyepiece to localise the glottis before tracheal tube's insertion. 7,8 We are conscious of the disadvantages of an endoscopic view due to secretions, blood or fogging, 7 but we think that it is the 'gold standard' for Bonfils fibrescope. In 2006, Biro et al. 9 proved that aptitude for endoscopic viewing, more than experience and skill in standard laryngoscopy, could improve the learning curve of rigid fibrescope utilisation, so the use of this device is not intuitive and needs a greater learning curve when compared with blind devices as Trachlight. 5-7 The Bonfils fibrescope was previously compared with the intubating laryngeal mask airway 10 after conventional laryngoscopy failed. The results of this study found a comparable success rate, but a significantly shorter time to intubation and a decreased postanaesthesia airway morbidity was noted in the Bonfils group. We believe that the possibility to advance the endotracheal tube under direct visualisation avoids some of the complications associated with intubation using blind devices. X-M. Transillumination-assisted orotracheal intubation: a comparison of the Bonfils fibrescope and the lightwand (Trachlight).
