We thank Xue et al (1) for their interest in our article and their excellent comments. We agree that our study does not suggest that awake bronchoscopic endotracheal intubation is superior to a direct laryngoscopic approach. Our case series merely describes one possible approach and does not make a direct comparison with other techniques. We were motivated to perform this study by our review of the literature, which revealed that there is no good data defining the best approach for airway management of patients with pulmonary hypertension and right heart failure suffering from acute respiratory failure. Prior literature mostly consists of case reports of hemodynamic collapse from standard approaches to airway management in this fragile population. In fact, the standard expert opinion on airway management for these patients has been to “avoid endotracheal intubation” whenever possible.
The limitations of our retrospective study do not allow us to comment on the amount of cough and exact timing of the administration of systemic sedatives. We appreciate the authors comments on the importance of understanding the pharmacokinetics of sedatives and agree that topical anesthesia approach does not anesthetize the trachea. We use the bronchoscope only as a stylet for the endotracheal tube and are careful to avoid touching the wall of the trachea. Therefore, we do not think that this technique requires more anesthesia of the trachea than other intubation strategies.
We hope that our article and the comments by Xue et al (1) encourage others to publish their experiences with airway management in patients in this patient population.