LAUSR

the authors’ use of the ‘hold up’ technique for bougie insertion. While debate could occur over the rotation of the Coud e tip, the need to advance the bougie until ‘hold up’ seems unwarranted. Seeing the bougie pass through the vocal cords with the videolaryngoscope should provide adequate confirmation of correct positioning, without the well-documented risk of bronchial trauma from the bougie tip at ‘hold up’ [2]. Finally, we would also like to question the authors’ statement that nasal intubation over a bougie significantly decreases the incidence and severity of nasopharyngeal trauma. In their paper, the authors quote, and use for their power analysis, a nasal trauma rate of 45% from the literature. They expected to see a reduction to 25% in their study group. The rate of bleeding in their controls was 68%, well above the published average, and even their ‘significantly reduced’ study group had a bleeding rate of 55%, again well above normal. It is difficult to conclude that this is a successful technique if the result is worse than one would normally expect to see and well below their predicted reduction in bleeding rates to 25%. The reason for the high bleeding rate in this study is doubtless multifactorial, but the high proportion of ‘learners’, with little or no experience with the nasal intubation techniques used in the study, would seem to play a significant part.