We thank Dr. Brock-Utne for his comments concerning our letter,1and we agree that there are several solutions to consider in this situation.

  1. Although we have insufficient data concerning this, we have experienced many more kinked endotracheal tubes (ETTs) than ETTs occluded by the cuff of the ETT. We do not believe that letting the cuff down should be the first step when a kinked ETT is far more probable than an occluded one.2Though the pilot balloon line inserts at 18 cm on the ETT used in this case, the actual endotracheal cuff itself is far distal to this insertion. The notion that a pilot balloon line could develop an aneurysm just after the point of insertion, which could partially occlude an ETT, seems unlikely.

  2. The Berman intubating airway is easily removed from around the ETT after intubation. The same features that make it easy to remove (the “breakaway” feature on one side and the “hinge” on the other side) also make it easy to insert. There is no need to fully open the mouth, as the teeth need only to be separated by the outside diameter of the airway. Soft tissue edema of the tongue and lips are frequently easy to overcome with the rigidity and form of the Berman airway.

  3. When a better method is available, trying to pass a catheter of any reasonable inside diameter through an ETT with a significant kink is probably not the best use of important time to restoring patency. In addition, ventilating through a very small diameter tube can lead to quickly increasing carbon dioxide levels, which may be of concern in open cranium neurosurgical cases such as this one.

*University of Utah School of Medicine, Salt Lake City, Utah.


Ogden LL, Bradway JA: Maneuver to relieve kinking of the endotracheal tube in a prone patient. Anesthesiology 2008; 109:159
Dorsch JA, Dorsch SE: Airway equipment: Tracheal tubes, Understanding Anesthesia Equipment, 4th Edition. Baltimore, Lippincott Williams & Wilkins, 1999, pp 604–7
Lippincott Williams & Wilkins