We thank Drs. Ji and Cui,  and Drs. Pino and Thomas  for their responses to our letter. 

Drs. Ji and Cui note that we did not fully describe preoxygenation practices or define oxygen desaturation in our letter.  We regret this omission, which was partly due to length concerns. Oxygen desaturation (Spo2) was defined as Spo2 greater than 90% or a further decrease from the patient’s baseline if baseline Spo2 was lower than 90%. We did not record how many patients received low-flow nasal cannula oxygen during their intubation attempts. High-flow nasal cannula oxygen was not used in our patient cohort. We agree that universal use of high-flow oxygen may reduce the incidence of oxygen desaturation we observed but note that high-flow oxygen delivery systems are not universally available in operating room environments.

We agree that droperidol’s sedative properties and ability to preserve cooperativity would have made it an effective anesthetic regimen for awake intubation.  However, after the Food and Drug Administration black box warning in 2001, the availability of droperidol in the United States dropped sharply and it was likely unavailable at Wake Forest during the time of our study (2009 to 2014). Currently, it has only limited availability at our home institutions (Massachusetts General Hospital, Dartmouth-Hitchcock Medical Center, University of Chicago Medical Center). In addition, there is a lack of evidence indicating a single anesthetic regimen, including droperidol, is superior to others in terms of safety, efficiency, and patient satisfaction. Therefore, we emphasized that large, randomized trials are necessary to optimize patient care during awake flexible bronchoscopic tracheal intubation.