The recent report in your journal on retrograde assisted fibreoptic intubation is interesting.₁ There are very few reports about this procedure and the article appears outstanding in this manner. However, it gives rise to a few concerns. The rarity of such reports itself is suggestive that any attempt at an invasive approach should be the last airway securing measure. This is likely either in emergencies or when the modern equipments are unavailable.₂ Also, the authors have not clearly mentioned of any advantages in passing the guidewire through the suction port over using main port (biopsy port) of the fibreoptic scope when the procedure needs to be done as quickly as possible. On the contrary, using the suction port would prevent the suction or the oxygen source being used.

It is very well understood that the case was presenting a challenging airway to the anaesthetist with limited mouth opening, small thyro-mental distance, absent neck movements and classified as Mallampati class III. The authors have not mentioned of attempting other airway securing measures like laryngeal mask airway (LMA) or supraglottic airways. These are recommended in the difficult airways protocols before attempting any invasive measure like cricothyroid puncture unless it is a cannot intubate cannot ventilate (CICV) scenario.₃ Another situation that demands cricothyroid puncture is a diagnosed imminent airway obstruction when it would stand a chance with trachiostomy as it might lead to CICV situation on induction of anaesthesia. There are case reports and studies on this that suggest combined approach of retrograde intubation with fibreoptic laryngoscopy₄,₅could be appropriate. Also an obscured vision of the laryngeal inlet in such cases would make this procedure more logistic.

The difficult airway guidelines₃ suggest using laryngeal mask airway (LMA) after a maximum of four failed attempts with direct laryngoscopy and then to plan secondary intubation with LMA or ILMA (intubating LMA). Cricothyroidotomy is associated with complications although rarely could be life threatening.₆ Hence it would be ideal to follow the safer evidence based procedures that are presented as guidelines than attempting an adventure at the cost of someone’s life. It is also suggested that all anaesthetists should know the cricothyrotomy as a part of their training among the manikin core skills.₃