Styletubation versus Laryngoscopy: A New Paradigm for Routine Tracheal Intubation

Round 1

Reviewer 1 Report

Dear colleagues!

Thank you for your interesting opinion, but I don’t fully understand why you publish previously published images in such quantities?

And if you did not perform these operations, then why are the sections called “Cases Presentation”.

First, I would like to see the null hypothesis, as well as a Materials and Methods section indicating the search keywords, databases, and depth of the literature search.

Tell me, how many sources were initially selected and how many remained after including keywords?

Why are the authors of the original studies not signed in the captions?

If these are your personal patients, then why is there no description of the inclusion and non-inclusion groups in the studies?

Why hasn't the sample size been calculated?

On line 614, the download link is not available (Error 404 - File not found)

Overall, I think the authors need to be more transparent about their results.

Author Response

Responses to the Reviewer-1

Comment-1: Thank you for your interesting opinion, but I don’t fully understand why you publish previously published images in such quantities?

Response-1: Thanks for your critical question. (1) Yes, we do plan to publish our articles with such specific airway management articles in large quantities. The purpose is to share our unique clinical experiences of applying “styletubation” which involved video-assisted intubating technique. Since 2016, we have universally and routinely applied such styletubation technique in our medical center on daily basis. Up to now, we have accumulated more than 55000 cases during the last 7 years. The results are amazing indeed. (2) Meanwhile, on topic of airway management, we believe the tenet is “to see is to believe”. We would like to share our images of styletubation with video-recordings as much as possible. The potential readers are then much easier to understand and to learn such technique. On the other hand, it is not easy to reach such goal because it is sometimes difficult to obtain the informed consents from the patients. We believe that we have not duplicated any images among our publications. It is because we have much more representative photos than enough obtained in the past 7 years. Thanks for your question.

Comment-2: And if you did not perform these operations, then why are the sections called “Cases Presentation”.

Response-2: Thanks for your critical question again. We apologize the misunderstanding we caused for the heading “case presentation”. In this “narrative review” article, it is our intention to present our unique clinical experiences to support our idea that styletubation be the plausible option for routine regular tracheal intubation for airway management. Yes, I personally did all the operations we presented in our articles, including all in this review article. I personally performed around 5000 anesthesia cases annually. For tracheal intubation, I did more than 200 cases monthly. After obtaining the patients’ informed consent, I recorded around 25 cases weekly. Therefore, in our hands, we have all kinds of representative photos to present almost all the clinical scenarios. Therefore, we would like to share our view on these cases presentation as many as possible. Thanks for your question.

Comment-3: First, I would like to see the null hypothesis, as well as a Materials and Methods section indicating the search keywords, databases, and depth of the literature search.

Response-3: Thanks for your critical question again. (1) This is not a prospectively or retrospectively designed clinical study. This is a narrative review article. Therefore, it is not our intention to quantitatively “compare” any parameters among various airway management tools or technique. It is then no “null hypothesis” in our review article. Namely, even it has been our belief all these years, we do not have position to hypothesize that styletubation is not different from other tools/techniques by setting null hypothesis here. (2) Currently, it is not our intention to present our narrative review article as those in the form of standard review form (e.g., scoping review, literature review, systematic review, meta-analysis, etc.). The main reason for this is the evidence for styletubation is scanty and then no power to compare with other airway modalities. Therefore, we do not feel it is necessary to go diving searching the literatures as the methods that conventional review applied.         

Comment-4: Tell me, how many sources were initially selected and how many remained after including keywords?

Response-4: Thanks for your critical question again. Similar to the comment-3, it is not our intention to go for SR/MA or other kinds. We understand the issue you brought up (e.g., the diagram below). Again, we would like to stress, in this early stage of development, the relevant literature regarding styletubation is scanty. That is why we have been devoted to create in the last 7 years.  

(https://doi.org/10.1186/s41182-019-0165-6)

Comment-5: Why are the authors of the original studies not signed in the captions?

Response-5: Thanks for your critical question again. All the photos were obtained from our clinical team, except the Figure 1, which was also kindly offered by our co-author (Dr. Alan Shikani).

Comment-6: If these are your personal patients, then why is there no description of the inclusion and non-inclusion groups in the studies?

Response-6: Thanks for your critical question. Again, the purpose to present “representative” cases in this narrative review article is to share our unique clinical experience by providing a clear and straightforward imaging of styletubation for tracheal intubation. There is no “inclusion-exclusion” here in this review article. The only “non-inclusion” group of the patients in this article is those who did not or refused to provide informed consents to us for using their case presentation.

Comment-7: Why hasn't the sample size been calculated?

Response-7: Thanks for your critical question. Again, this is a narrative review article set at the beginning of submission process. This is not a prospective/retrospective clinical study and therefore, we believe, there is no issue of sample size calculation.

Comment-8: Why On line 614, the download link is not available (Error 404 - File not found)

Response-8: Thanks for your critical question again. The supplementary materials (line 616) will be taken care of as the post-production issue. The images have been currently presented in each figure.

Comment-9: Overall, I think the authors need to be more transparent about their results.

Response-9: Thanks for your critical question again. This is exactly why we are eager to share our clinical experiences about styletubation with the academic community. Especially, we present the “cases” with figures and video to attest our notion, performance, and proposal. We understand that such narrative review article in combination of case presentation is not common, as we have explained in this reply. The reason is the relevant literature about styletubation is scanty currently. Since this article is totally different from systematical analysis or meta-analysis, we believe there is no issue of transparency about “literature search strategies”. Many thanks for your excellent critics and opinions.

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you very much for your very brilliant paper.

Despite the great evolution of videolaryngoscope systems for intubation and the use of dedicated disposable fiberoptic bronchoscopes for intubation, the techniques, easy for videolaryngoscopes, less easy for bronchoscopes, require some learning curve.

From your experience, the quality of the images reported and the times described for intubation, the presenatta technique seems fascinating, safe and above all guaranteed success.

Compliments

Author Response

Responses to the Reviewer-2

Comment-1: Thank you very much for your very brilliant paper.

Response-1: Thanks for your encouragement.

Comment-2: Despite the great evolution of videolaryngoscope systems for intubation and the use of dedicated disposable fiberoptic bronchoscopes for intubation, the techniques, easy for videolaryngoscopes, less easy for bronchoscopes, require some learning curve.

Response-2: Thanks for your excellent view on the optic devices for tracheal intubation which have been developed and evolved since two decades ago. I am sure that you are among the experts of airway management. We are pleased to share our unique clinical experiences of styletubation with the academic community in the area of airway management.

Comment-3: From your experience, the quality of the images reported and the times described for intubation, the presenatta  technique seems fascinating, safe and above all guaranteed success. Compliments

Response-3: Thanks for your encouragement and constructive comment. Yes, we would like to share our unique and excellent clinical experiences of applying styletubation for routine and regular tracheal intubation. In addition, we would like to share such application of styletubation for tracheal intubation in the scenarios of difficult airway too. Many thanks.

Author Response File: Author Response.pdf

Reviewer 3 Report

I have to apologize, that I simply do not understand This manuscript.

actually, the authors ist on a treasury of 55.000 VS intubations. Why did they not present the original data in a retrospektive analysis? They can compare it to the later invented VL. Since every newly invented method may pose some difficulties it May be interesting how VL May perform compared to the Long established VS. Normally, most anesthestists are more qualified in VL and alternative methods that are introduced in Addition perform poorly which is some dort of bias.

in your Hospital it is Vice versa and This May help to asses the effectiveness of VS compared to VLmore precisely since you may be able to provide data that is biased compared to most data the the authors  way round.

in this regard I also do not understand the case Report Series. To my opinion the authors should decide what sort of article this should be: Review, case Report Series of original article that I would prefer. Then they should Focus their efforts on this kind of manuscript. I do Not See Andacht dvantage of mixing this up.

l. 59 ff. the Main Statement is Doubled in the following sentences

Author Response

Responses to the Reviewer-3

Comment-1: I have to apologize, that I simply do not understand This manuscript.

Response-1: Thanks for your time and efforts on our manuscript. Let us explain in more details as below and wish to tell our story in an easier way.

Comment-2: actually, the authors ist on a treasury of 55.000 VS intubations. Why did they not present the original data in a retrospektive analysis? They can compare it to the later invented VL. Since every newly invented method may pose some difficulties it May be interesting how VL May perform compared to the Long established VS. Normally, most anesthestists are more qualified in VL and alternative methods that are introduced in Addition perform poorly which is some dort of bias.

Response-2: Thanks for your critical question. (1) This is a narrative review and supported by several typical cases presented in this paper. Among our 55000-cases database, we did not record all the necessary airway data needed for a research paper. These include patient’s demo data, airway parameters, intubating conditions, peri-op airway adverse events. This kind of database establishment requires financial support and institution back-up (e.g., manpower, e-system). Therefore, for this moment, we are eager to present our clinical experiences by case/case series presentation and tackle various clinical scenarios. (2) We understand the power of a well-designed clinical study (either prospective or retrospective) or a systematic/meta-analysis. A well-controlled clinical study is of absolute importance and value. However, we would like to emphasize here that to perform clinical trial of airway management is extremely difficult due to the ethics issue.

Chapter 30 - Ethical issues arising in airway management from Section 4 - Ethics and the law. Published online by Cambridge University Press: 10 January 2011. By Andrew D.M. McLeod and Steven M. Yentis.

Core Topics in Airway Management , pp. 287 - 292

DOI: https://doi.org/10.1017/CBO9780511760310.031

Since we are the only hospital in the world where the styletubation is universally and systematically applied as the first-lined tracheal intubation tool on daily basis. In addition, such regularly and routinely use styletubation technique is not only in the operating rooms, but also in the emergency rooms, intensive care units, general wards and even for out-of-hospital rescue emergency service. Therefore, for this moment, we are eager to share our unique clinical experiences with the academic community. We also welcome all the challenges and arguments from the professional peers. With our paper, we would like to answer all the doubts and controversial points by our presentation.

Comment-3: in your Hospital it is Vice versa and This May help to asses the effectiveness of VS compared to VLmore precisely since you may be able to provide data that is biased compared to most data the the authors  way round.

Response-3: Thanks for your critical comment. Yes, indeed, to conduct a different-scale retrospective study on styletubation is under way in our hospital. Again, with the inherent restraint of ethics, we need to be carefully and cautiously to adopt the strategies to design such clinical prospective/retrospective studies regarding airway management.

Comment-4: In this regard I also do not understand the case Report Series. To my opinion the authors should decide what sort of article this should be: Review, case Report Series of original article that I would prefer. Then they should Focus their efforts on this kind of manuscript. I do Not See Andacht dvantage of mixing this up.

Response-4: Thanks for your excellent and critical comment. We do published, and continue to do so, the case-report, cease series report on the issue of styletubation. Meanwhile, we also try to present this new paradigm issue as a form of review article (like this manuscript) which we also provide evidence of cases in it. Currently, there is no room for standard systematic review or meta-analysis on the styletubation because the relevant evidence is scanty. At present, we would like to present our notion in this article as a “narrative review article” which is supported by several cases presentation in the text.

Comment-5: l. 59 ff. the Main Statement is Doubled in the following sentences

Response-5: Thanks for your correction. The contents between lines 51-57 are about the conventional concept of airway anatomy for tracheal intubation, including several manipulations. The paragraphs are followed by specific comments on TAAT between lines 57-59. From lines 60-64, the inherent difficulties of DL are emphasized. The entire paragraph here is paved for the discussion of VL and VS in the following paragraphs. Thanks again for your careful reading and comments.  

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Dear colleagues!

The principle “seeing is believing” is more suitable for philosophical debate than for medicine, which is based on the principles of evidence.

Due to the fact that the authors provide a significant number of personal images showing the routing of Styletubation versus laryngoscopy, I consider it appropriate to present the material in the form of a clinical recommendation based on personal experience. It will be useful if the authors more actively cite their own previously published studies that confirm and prove the effectiveness, safety and effectiveness of the proposed method.

You write that “Up to now, we have accumulated more than 55,000 cases during the last 7 years. The results are amazing indeed,” but you do not support this with factual evidence, except for photographs in the text.

I would like to draw your attention in particular to the principles of evidence-based medicine and the procedure for presenting data: unfortunately, even the scant information about little-used techniques does not speak in favor of a method that, given the advantages that you write about, could be used successfully and everywhere

Author Response

Response to the Reviewer-1

March 20, 2024

Comment-1: Dear colleagues! The principle “seeing is believing” is more suitable for philosophical debate than for medicine, which is based on the principles of evidence.

Response-1: Thanks for your comment. Cannot agree with you more.

Comment-2: Due to the fact that the authors provide a significant number of personal images showing the routing of Styletubation versus laryngoscopy, I consider it appropriate to present the material in the form of a clinical recommendation based on personal experience. It will be useful if the authors more actively cite their own previously published studies that confirm and prove the effectiveness, safety and effectiveness of the proposed method.

Response-2: Thanks for your excellent suggestion. Indeed, we would like to continue to present our own experience of using styletubation. Our previous experiences have been cited as the references 37 to 48 (i.e., 12 articles all together so far have been published). We cannot agree with you more regarding the statement of “[to present the marterial in the form of a clinical recommendation based on personal experience.” We have carefully expressed this view on the page 18, lines 592-609.  

Comment-3: Due to You write that “Up to now, we have accumulated more than 55,000 cases during the last 7 years. The results are amazing indeed,” but you do not support this with factual evidence, except for photographs in the text.

Response-3: Thanks for your absolutely correct view. In the near future, we will conduct a retrospective medical record-based analysis on the effectiveness and safety of styletubation from 2017 to 2023. Again, such notion has been emphasized on the page 18, lines 592-609. For this moment, the readers should take our view based on only our “clinical experience-based practical view”.

Comment-4: I would like to draw your attention in particular to the principles of evidence-based medicine and the procedure for presenting data: unfortunately, even the scant information about little-used techniques does not speak in favor of a method that, given the advantages that you write about, could be used successfully and everywhere

Response-4: Thanks for your absolutely just comments. As we stated in the section of “case study limitation”, page 18, lines 592-609, we fully noted the necessary information and caution to interpret our clinical experience-based statement. Your comments on the EBM are absolutely correct. We will continue to dive in the EBM on this particular issue. Many thanks for your note.  

Author Response File: Author Response.pdf

Reviewer 3 Report

None

Author Response

The authors would like to express our gratitude to the reviewer-3 for the excellent feedback and comments.