Facilitating combined use of an Airtraq® optical laryngoscope and a fiberoptic bronchoscope in patients with a difficult airway

Abstract

To the Editor, We congratulate Drs. Gomez-Rios and Nieto Serradilla on their successful tracheal intubation using a combination of an Airtraq optical laryngoscope (Airtraq), Airtraq video camera, Airtraq wireless monitor (Prodol Meditec S.A., Vizcaya, Spain), and a fibreoptic bronchoscope (FOB) after failed intubation in a patient with a grossly distorted airway due to compression by a cervical tumour. We too have employed this combined technique in both adult and pediatric patients with difficult airways. In our experience, an important advantage of this approach is the ease and precision of FOB-guided intubation using the Airtraq; inserting the Airtraq to lift the patient’s tongue and jaw can achieve a clear airway for fibroscopy. Furthermore, by providing a clear view of the airway, the external monitor allows the FOB and Airtraq operators to observe simultaneously each step during the procedure. This approach is especially suitable in situations where the glottis cannot be visualized adequately by the Airtraq, either with or without the epiglottis, i.e., in a CormackLehane grade 3 or grade 4 view. In their report, the authors do not specify the type and manufacturer of the FOB used in this case. From Panel C of the Figure, we speculate that an adult FOB with an outer diameter of at least 4 mm was inserted through a 7.0-mm polyvinyl chloride endotracheal tube (ETT) mounted in the guiding channel. Also, the ETT tip was placed within the vicinity of the glottis during fibroscopy. Our experience suggests that inserting a large FOB via the ETT and placing the ETT tip close to the glottis can cause difficulties in performing fibroscopy and in directing the FOB tip into the glottis. Maneuverability of the anterior bending section of the FOB is decreased by limiting the spaces between the inner wall of the ETT and the outer wall of the FOB and between the glottis and the ETT tip. In our practice, when tracheal intubation with an Airtraq fails, we prefer to use two approaches to facilitate FOBguided intubation using the Airtraq: 1) If the operator plans to insert a FOB through the ETT mounted in the guiding channel, the ETT tip should be placed just at the distal end of the guiding channel to obtain an adequate space for the fibroscope. A small FOB is recommended to improve maneuverability of the fibroscope (Figure). 2) If a small FOB is not available, we suggest to withdraw the ETT from the guiding channel and to thread the ETT over a large FOB. The FOB loaded with the ETT can then be passed through the guiding channel toward the larynx. After the larynx is exposed by fibroscopy, the FOB can be advanced into the trachea through the glottis, and subsequently, the ETT can be railroaded over the FOB within the guiding channel into the trachea. With this approach, it is relatively easy to perform fibroscopy with the FOB and to insert the FOB and the ETT into the trachea.