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Bougie vs. guidewire for tracheal intubation

Ponnusamy et al. reported a lower incidence of pharyngolaryngeal complaints associated with wire-guided orotracheal intubation compared with using bougieguided intubation (28.3% vs. 48.3% for wire-guided and bougie group, respectively; p = 0.01) [1]. The finding is compatible with that of a previous study demonstrating possible impingement on laryngeal structures due to the large gaps in diameter between the introducer and the tracheal tube [2]. Accordingly, the study by Ponnusamy et al. [1] utilised a modified reinforced silicone tracheal tube with a built-in guide channel [3] to overcome this problem by using the guidewire technique. Although the findings in that study [1] may provide significant insights into the improvement of patient safety, some important issues need to be clarified. Despite the lack of significant difference in the first attempt intubation rate (95% vs. 93.3%) and relatively minor laryngeal trauma limited to grade 1 (i.e. mild abrasion in glottis or subglottis and mild vocal fold oedema) in both groups [1], the bougie-guided group had a significantly higher incidence of pharyngolaryngeal. This finding seems especially paradoxical after taking into consideration that there were more patients with pharyngolaryngeal complaints than those with grade-1 laryngeal trauma in each group (Table 2 [1]). Therefore, the laryngeal trauma score appears to be unrelated to the incidence of pharyngolaryngeal complaints that occurred even in patients without notable laryngeal trauma (i.e. grade 0). To account for the above discrepancy, it would be helpful to have information on the intubation time (e.g. from insertion of the introducer into the trachea to confirmation of tracheal intubation by capnography); the difficulty in tube placement assessed using an objective standardised grading system [4]; tracheal tube cuff pressure; and the duration of intubation, that have been reported to be associated with the incidence of pharyngolaryngeal complaints [5]. Such relevant information, however, was not available in this article [1]. Could we invite the authors to comment on each of these points, as they are of clinical interest to the readers?