Emergency airway management using the Bonfils intubation fiberscope

Abstract

The difficult airway is a challenge to both the emergency physician and the anesthesiologist. Its incidence in the Emergency Department (ED) is understandably higher as there is a disproportionately larger number of patients requiring airway management as a result of acute medical or surgical conditions, which by themselves contribute to the difficulty and because the patients are not prepared for intubation as during elective surgery [1]. Many videobased intubation devices have been developed as an alternative to flexible fiberoptic bronchoscope intubation and direct laryngoscopy for difficult airway management and various rigid fiberoptic stylets have been proposed [2], including the Bonfils retromolar intubation fiberscope, a recently re-discovered airway device designed in the 1980s (Karl Storz Co., GmbH, Tuttlingen, Germany) (Fig. 1, 2). It is a reusable, rigid, straight fiberoptic device with a 40 curved tip, 40 cm long and 5 mm in diameter. A flexible eyepiece is mounted on the handle of the scope. The fiberscope has a connector that fits onto the 15-mm tracheal tube adapter and thereby allows oxygen insufflation. A cold light source or a small battery handle can be attached to the stylet handle. The tip of the Bonfils intubation fiberscope is positioned just proximal to the tip of the attached endotracheal tube, thereby preventing the lens from being soiled with blood or secretions, and to reduce any risk of mucosal trauma. We report on ten patients in whom the Bonfils intubation fiberscope was used for emergency endotracheal intubation in an Emergency Department (ED). All described cases were performed by a specialist in Anesthesia and Intensive Care Medicine, experienced in airway management procedures. The following is a paradigmatic case: a 52-year-old man was admitted to the ED with blunt thoraco-abdominal trauma, with multiple open fractures. Potential cervical spine injury was assumed by the first responders, and treated with a rigid cervical immobilization collar. The primary survey, revealed obesity (BMI: 38). The blood pressure was 70/50 mmHg, pulse rate 112 beats/min, respiratory rate 40 breaths/min, and the oxygen saturation 89% on a non-rebreathing face mask (FiO2: 1). He was alert but confused (GCS 11): the patient needed a definitive airway. He had several predictors of difficult intubation: obesity, limited neck mobility, limited mouth opening (mouth opening less than three finger breadths). The patient was supine on a long spine board. Preoxygenation was performed with 100% O2 for at least 3 min by a tight seal facemask. Bag mask ventilation (BMV) was not considered difficult, and rapid sequence intubation was performed with intravenous midazolam 5 mg, ketamine 100 mg, and succinylcholine (100 mg). The Bonfils fiberscope, armed with an 8-mm inner diameter standard endotracheal tube, was inserted with the right retromolar approach to avoid cervical movements, with a jaw thrust maneuver performed with the left hand to increase the size of the retropharyngeal space. Advancing the Bonfils into the glottic aperture, the TT was gently and successfully inserted by a counterclockwise anterior rotation under direct vision of the trachea. Tube position was further checked with chest auscultation and capnography, and the intubation time was less than 1 min. In addition to the case described above in detail, the Bonfils intubation fiberscope was electively used in nine R. M. Corso (&) G. Gambale E. Piraccini Emergency Department, Anaesthesia and Intensive Care Unit, Ospedale ‘‘G.B. Morgagni-Pierantoni’’ Viale Forlanini, 34, 47100 Forli, Italy e-mail: rmcorso@gmail.com