Bonfils Intubation Fiberscope Research Articles

Comparison of video-stylet and conventional laryngoscope for endotracheal intubation in adults with cervical spine immobilization: A PRISMA-compliant meta-analysis.

Background:Although minimization of cervical spine motion by using a neck collar or manual in-line stabilization is recommended for urgent tracheal intubation (TI) in patients with known or suspected cervical spine injury (CSI), it may worsen glottic visualization. The overall performance of video-stylets during TI in patients with neck immobilization remains unclear. The current meta-analysis aimed at comparing the intubation outcomes of different video-stylets with those of conventional laryngoscopes in patients with cervical immobilization.Method:The databases of Embase, Medline, and the Cochrane Central Register of Controlled Trials were searched from inception to June 2021 to identify trials comparing intubation outcomes between video-stylets and conventional laryngoscopes. The primary outcome was first-pass success rate, while secondary outcomes included overall success rate, time to intubation, the risk of intubation-associated sore throat, or tissue damage.Results:Five randomized controlled trials published between 2007 and 2013 involving 487 participants, all in an operating room setting, were analyzed. The video-stylets investigated included Bonfils intubation fiberscope, Levitan FPS Scope, and Shikani optical stylet. There was no difference in first-pass success rate (risk ratio [RR] =1.08, 95% confidence interval [CI]: 0.89–1.31, P = .46], overall success rate (RR = 1.06, 95% CI: 0.93–1.22, P = .4), intubation time [mean difference = 4.53 seconds, 95% CI: –8.45 to 17.51, P = .49), and risk of tissue damage (RR = 0.46, 95% CI: 0.16–1.3, P = .14) between the 2 groups. The risk of sore throat was lower with video-stylets compared to that with laryngoscopes (RR = 0.45, 95% CI: 0.23–0.9, P = .02).Conclusion:Our results did not support the use of video-stylets as the first choice for patients with neck immobilization. Further studies are required to verify the efficacy of video-stylets in the nonoperating room setting.

Bonfils intubation fiberscope versus C-MAC videolaryngoscope: hemodynamic stability and incidence of sore throat in endotracheal intubated patients

Introduction: Hemodynamic stability at laryngoscopic intubation is influenced by mechanical stimuli on the affected area of the oropharynx. The use of appropriate tools can lower mechanical stimuli and lead to a better outcome. The purpose of this study was to determine whether the use of Bonfils intubation fiberscope provided a better hemodynamic stability, and decreased the incidence of a sore throat compared to Macintosh videolaryngoscope. Materials and Methods: We conducted a non-blind randomized controlled trial. It was conducted at Sanglah Hospital, Indonesia, in September to October 2016 with a sample of 50 people. The sample was divided into two groups. The patients were induced by propofol TCI target effect 4 µg/ml and analgesia with fentanyl 2 mcg/kg. Hemodynamic conditions assessed since the induction, one minute before intubation, and one minute, three minutes, and five minutes after laryngoscopy intubation. A sore throat was evaluated before and after treatment. Results: The MAP value and pulse rate in one minute and three minutes after laryngoscopy intubation in CMAC group were significantly higher compared to Bonfils group (p<0.001). The proportion of a postoperative sore throat is significantly different between the two groups (p=0.042). Conclusion: Bonfils intubation fiberscope proved better in providing hemodynamic stability and decreased the incidence of a sore throat compared to Macintosh videolaryngoscope in patients underwent general anesthesia.Â

A comparison of the transillumination-assisted technique versus midline approach technique in novices: a prospective randomized controlled trial about the Bonfils intubation fiberscope

BackgroundThe present study aimed to compare the safety and efficacy for novices to conduct intubation with the Bonfils intubation fiberscope (BIF) using the transillumination-assisted or midline approach technique in patients with normal airways.MethodsIn this prospective randomized control study, 10 trainees were assigned to the transillumination-assisted technique group (T group) or the midline approach technique group (R group). Each trainee was required to conduct intubation in 50 patients. The primary outcome was intubation time. The secondary outcomes were success rate (%), number of attempts, and complications.ResultsAmong the cases of successful intubation, the intubation time was not significantly different between the two groups (P > 0.05). The overall success rate of intubation was not significantly different between the two groups (P > 0.05). The intubation success rates at the first, second, and third attempts as well as the average intubation times were similar between the two groups (P > 0.05), but in patients receiving successful intubation at the second attempt, the intubation time was longer in the T group (P = 0.0006). The incidences of dry throat, sore throat, and hoarseness were higher in the T group (all P < 0.05).ConclusionsFor patients with a normal airway, the transillumination-assisted technique was unlikely to increase the success rate of intubation with the BIF compared with the midline approach technique, but led to more complications.Trial registrationChiCTR-INR-16009967, retrospectively registered on November 22, 2016

Comparison of the C-MAC Videolaryngoscope and Rigid Fiberscope with Direct Laryngoscopy in Easy and Difficult Airway Scenarios: A Manikin Study

BackgroundIntubation is a fundamental skill in maintaining adequate oxygenation and ventilation of seriously ill patients. ObjectivesTo compare the C-MAC video laryngoscope and Bonfils intubation fiberscope with direct laryngoscopy in simulated easy and difficult airway scenarios. MethodsThis was a prospective, randomized-controlled cross-sectional study. Thirty emergency medicine residents attempted to intubate a manikin using four progressively more difficult airway settings (normal airway [scenario 1], cervical spine immobilization [scenario 2], cervical spine immobilization + tongue swelling scenario [scenario 3], and cervical spine immobilization + tongue swelling + limited jaw opening scenario [scenario 4]) with both the C-MAC video laryngoscope and the Bonfils intubation fiberscope and direct laryngoscope. ResultsIn the first and the second scenarios, there were no statistically significant differences between the airway devices in terms of the duration of endotracheal intubation, the viewing duration of the glottic opening, and endotracheal tube insertion time. There was no statistically significant difference between the laryngoscopes in terms of the duration of endotracheal intubation and endotracheal tube insertion time in the third scenario. The overall success rates and the viewing duration of the glottic opening were shorter with the C-MAC and Bonfils in scenarios 3 and 4. Furthermore, the duration of intubation was better with Bonfils in scenario 4. The severity of dental trauma was lowest with the Bonfils in all scenarios. The device difficulty score was greatest with the Macintosh blade, except in the normal airway scenario. The most preferred airway device was the C-MAC. ConclusionThe Bonfils and C-MAC enabled better visualization of the glottic opening when compared with the Macintosh laryngoscope.

Hemodynamic responses to endotracheal intubation: A comparison between Bonfils intubation fiberscope and direct laryngoscopy

Background: Laryngoscopy and intubation are intensely stimulating procedures and can induce marked sympathetic responses. We hypothesized that by minimizing the oropharyngeal stimulus with Bonfils rigid fiberscope intubation, the hemodynamic responses to endotracheal intubation will be lesser. Therefore, we compared Bonfils intubation with conventional direct laryngoscopic intubation in adult patients with normal airway. Materials and Methods: Sixty adult patients of either sex, belonging to American Society of Anesthesiologists grade 1 or 2, were randomized into Bonfils group and laryngoscopy group, and studied over a 2-year period. Anesthet ic technique was standardized in both the groups. Hemodynamic variables were recorded at pre-induction, induction, post-induction at laryngoscopy and intubation, thereafter for every minute for 10 min, and half hourly till the end of surgery for both the groups. Intubation time, intubation attempts, and postoperative complications like hoarse voice and sore throat were compared between the two groups. Results: There was no statistically significant difference between the two groups with respect to systolic blood pressure, mean blood pressure, and heart rate changes throughout the study period. There was a statistically significant difference in the diastolic blood pressure (DBP) values between the groups (P < 0.05) for the first 10 min following intubation. The time required for intubation was significantly longer in the Bonfils group (36 ± 6 s) compared to the laryngoscopy group (28 ± 6 s) (P = 0.000). The incidence of postoperative sore throat (P = 0.009) and hoarseness of voice (P = 0.045) was significantly lesser in the Bonfils group compared to the laryngoscopy group. Conclusion: There was no clinically significant difference in the hemodynamic changes following intubation using either Bonfils fiberscope or conventional laryngoscope. Bonfils intubation required longer time, but was associated with lesser incidence of sore throat and hoarseness of voice when compared to laryngoscopic intubation.

Bougie assisted left molar approach to laryngoscopy after failed intubation with Bonfils intubation fiberscope in a patient with anticipated difficult airway

Management of Difficult airway (DA) remains a challenge for the anesthetists globally. Recent literature recommends numerous devices like various supraglottic devices, fiberoptic bronchoscopes, video laryngoscopes, etc. Most of us are inclined to use advanced intubation gadgets in a scenario of difficult intubation. But these may have limitations like non-availability, unfamiliarity, time taken to assemble them etc. Present case report highlights the importance of a simple technique of bougie assisted left molar approach to direct laryngoscopy with OELM in a DA scenario where an advanced gadget like Bonfils intubation fiberscope could not help in securing the airway.

A Comparison Between the Bonfils Intubation Fiberscope and McCoy Laryngoscope for Tracheal Intubation in Patients with a Simulated Difficult Airway

The Bonfils Intubation Fibrescope (Bonfils) and the McCoy laryngoscope (McCoy) are airway devices designed to assist tracheal intubation in difficult cases. Individually, both the Bonfils and McCoy have demonstrated superiority to the Macintosh laryngoscope in a simulated difficult airway. In this study, we compared the Bonfils with the McCoy laryngoscope in patients whose tracheal intubation had been intentionally hindered. Our primary hypothesis was that there is a significant difference in the rate of success for tracheal intubation when using the Bonfils or McCoy laryngoscope in patients with an intentionally hindered airway. Patients undergoing elective surgery and requiring general anesthesia and endotracheal intubation were randomized to have intubation performed with either the Bonfils or McCoy laryngoscope. All patients were fitted with a hard cervical collar to simulate a difficult airway. Data collected included the success rate of endotracheal intubation, the time taken for intubation, the number of attempts required, the use of further aids to intubation, hemodynamic variables, and the incidence of adverse events. The primary end point was the relative rate of successful tracheal intubation. Categorical outcome measures were compared using the χ test, or Fisher exact test where appropriate, and the Mann-Whitney U test or unpaired Student t test where data were continuous. For the nonnormally distributed data, log transformation was adopted, and t test was performed if normalcy was achieved. Sixty adult patients were recruited and randomized into 2 groups of 30 patients each. There was no difference in the rate of successful intubation between groups (95% confidence interval [CI], -11.6% to 11.6%), with a 100% success rate achieved in both groups. We found no statistically significant differences between groups in the time taken for intubation (P = 0.32, 95% CI, 0.90-1.41) and percentage of single attempts (P = 0.47, 95% CI, -30.3% to 9.7%). However, further aids to intubation were required more frequently when using the McCoy laryngoscope (P < 0.001, 95% CI, 0.17-0.46), with 18 patients in the McCoy group requiring the use of an elastic bougie, and no patients in the Bonfils group requiring any aids. There were no significant differences found in the rates of adverse events. In the hands of trained operators, there appears to be no clinically significant difference in success, time to intubation, or adverse outcomes, when comparing the Bonfils with the McCoy laryngoscope, in the setting of a simulated difficult airway. The choice to use either device should remain based on appropriate patient selection, available aids, individual operator's experience, and economic circumstances.

Bonfils Fiberscope and McCoy Laryngoscope Equivalent in Simulated Difficult Intubations

The Bonfils Intubation Fiberscope is a rigid optical stylet with a 40° curved tip onto which an endotracheal tube is loaded and passed through the

The use of the Clarus Video System for double-lumen endobronchial tube intubation in a patient with a difficult airway

The use of the Clarus Video System for double-lumen endobronchial tube intubation in a patient with a difficult airway

Use of the Bonfils Intubation Fiberscope in Patients with Limited Mouth Opening

Airway management of patients with very limited mouth opening remains a challenge for the anaesthetist. We describe the use of the Bonfils Intubation Fiberscope for awake intubation in two patients with a very limited mouth opening. In the first case, a 60-year-old 80 kg female, scheduled for a right modified radical mastectomy for infiltrating ductal carcinoma (15 mm mouth opening, a short thick neck, limited neck extension, and a Mallampati class 4 airway), the Bonfils was advanced via the retromolar technique. In the second patient, a 34-year-old male, scheduled for a surgical tracheotomy for right tonsillar cancer, due to a neoplastic infiltration of the right temporomandibular joint (7 mm mouth opening and limited neck movement), the Bonfils was advanced using the midline approach. The Bonfils is a reusable, rigid, straight fiberoptic device with a curved tip, is 5 mm in diameter, and has several advantages: it is quick and easy to use, more cost effective than a flexible fiberscope, and is safe in expert hands, thanks to its smaller diameter. Our conclusion is that awake BIF intubation is a reliable, atraumatic, and well-tolerated procedure to secure a safe airway in patients with a limited mouth opening.

Emergency airway management using the Bonfils intubation fiberscope

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

A comparison of Bonfils intubation fiberscopy and fiberoptic bronchoscopy in difficult airways assisted with direct laryngoscopy

BackgroundTo evaluate the usefulness of Bonfils intubation fiberscope assisted by direct laryngoscopy (BIF-DL) and flexible fiberoptic bronchoscope assisted by direct laryngoscopy (FOB-DL) using video recording in cases of unanticipated difficult intubation with respect to the time required to visualize the vocal cords and place the endotracheal tube. We compared two fiberscopes in patients with authentic difficult airways.MethodsIn this randomized, controlled clinical trial, 40 patients (grade 3 according to grades of difficulty in laryngoscopy), scheduled for surgery under general anesthesia were randomly allocated to BIF-DL group or FOB-DL group. Number of attempts, time required for visualization of the vocal cord (T1) and placement of the endotracheal tube (T2) from insertion of instrument during the last successful attempt, and duration of scope manipulation during all attempts (Ttotal) were recorded. If intubation failed with one method, the other method was tried; these cases were then excluded. The incidence of sore throat and hoarseness was assessed.ResultsT1, T2, and Ttotal were significantly shorter in BIF-DL group (T1: 21.9 ± 8.2 sec vs. 80.4 ± 29.9 sec, P < 0.001, Ttotal: 77.9 ± 41.2 sec vs. 145.5 ± 83.9 sec, P = 0.003). In two cases, it was impossible to intubate with BIF-DL, but the procedure was subsequently successful using fibreoptic bronchoscope.ConclusionsIntubation of difficult airways can be performed more rapidly with BIF-DL, but sometimes it may not be possible to intubate with the scope.

Prehospital emergency endotracheal intubation using the Bonfils intubation fiberscope

Among all prehospital emergency intubations, difficulties occur in 7-10%. Furthermore, intubation conditions often worsen when the cervical spine is immobilized in trauma patients. We report on six patients in whom the Bonfils intubation fiberscope, a reusable, rigid fiberoptic device, was used for emergency endotracheal intubation in the field. Three of these patients had an anticipated or unanticipated difficult airway: two trauma patients with immobilized cervical spine and one patient in cardiac arrest in whom direct laryngoscopy failed twice. Endotracheal intubation with the Bonfils intubation fiberscope was successful in all cases in the first attempt. The Bonfils intubation fiberscope therefore demonstrated its value as an additional airway management device in both emergency and prehospital settings.

Using the Bonfils Intubation Fiberscope with a Double-lumen Tracheal Tube

Several surgical procedures require single-lung ventilation. Because a double-lumen tube (DLT) allows for independent ventilation therapy (e.g. , continuous positive airway pressure), suctioning, and bronchoscopy of each lung, the DLT is the accepted standard for the treatment of patients undergoing thoracic surgery.1A difficult intubation in this subset of patients is particularly challenging because tube insertion is impeded by the special shape of the DLT and the two separate cuffs, which can be damaged by the patient’s teeth and during repeated insertion maneuvers using intubation tools with sharp surfaces.Recently, in two patients scheduled to undergo a minimally invasive direct coronary artery bypass procedure requiring DLT insertion, direct laryngoscopy failed. Because at our institution the Bonfils intubation fiberscope (Karl Storz GmbH, Tuttlingen, Germany), a rigid fiberscope with a curved tip, is routinely used for managing unexpected as well as anticipated difficult airways,2,3we decided to use the device to aid in DLT placement. The Bonfils intubation fiberscope has a length of approximately 40 cm and an OD of 5 mm. According to the manufacturer, tracheal tubes with an ID of 5.5 mm or greater and a length of 39 cm or less may be used. The length of the DLTs (including tube connector) used in our cases is approximately 42 cm, and the largest ID of the bronchial lumen is approximately 5.1 mm (37 French) and 5.3 mm (39 French), respectively. Usually, the tube is too long for insertion of a Bonfils intubation fiberscope. After shortening both the tracheal and the bronchial connectors to a complete length of 38.5 cm and after ensuring adequate lubrication of the scope with silicone spray, however, the tube’s bronchial lumen was mounted on the scope easily (fig. 1). Shortening of the proximal connectors did not prevent connecting them to the endotracheal tube adapter and subsequently to the right angle adapter attached to the breathing circuit.Using the Bonfils intubation fiberscope, the patient’s mouth is opened, and the scope inserted from the right side of the mouth along the molars after the patient’s head is adjusted in a neutral position. With the insertion of the device, the anesthesiologist performs a jaw-thrust maneuver with his or her left hand to enhance the retropharyngeal space. After this, guided by the right hand, the Bonfils intubation fiberscope is advanced in the glottic aperture. The tube is then released from the scope with the left hand (or by an assistant) and inserted into the trachea under direct visualization. Sometimes, performing simultaneous laryngoscopy with a conventional Macintosh blade by a second anesthesiologist may be helpful to lift up a large tongue impeding advancement of the fiberscope. Finally, the correct position of the tube must be verified with a fiberoptic bronchoscope, because the rigid Bonfils intubation fiberscope should not be advanced in the trachea.In the two cases denoted, the Bonfils intubation fiberscope was an effective tool for placing a DLT. The time to intubation was clinically acceptable, and no damage occurred with respect to the patient’s teeth or soft tissues. Importantly, the cuffs were intact after placement despite a very desolate set of teeth in one patient. The right-sided insertion approach of the scope along the molars may be advantageous in such cases, because touching the front teeth is avoided, and molars are not as sharp-edged as the anterior and canine teeth.Few intubation tools are suitable for DLT placement. The fiberoptic bronchoscope, which has evolved as an accepted standard for management of the difficult airway,4may not be suitable for oral DLT insertion. The limited ID of the bronchial lumen of the DLT only allows use of a relatively small fiberoptic bronchoscope, and elastic oropharyngeal soft tissues, especially a large tongue, may prevent successful passage through the mouth. In conclusion, the Bonfils intubation fiberscope may be used with DLTs of 37 French or greater after appropriate tube shortening in patients with a difficult airway anatomy.* University Hospital Schleswig-Holstein, Campus Kiel, Germany. bein@anaesthesie.uni-kiel.de

Success rate of intubating with the Bonfils Intubation Fiberscope. A pilot study to evaluate the difference between novice and staff anaesthetists

Success rate of intubating with the Bonfils Intubation Fiberscope. A pilot study to evaluate the difference between novice and staff anaesthetists

Generating a learning curve for the Bonfils Intubation Fiberscope. A pilot study evaluating the difference between novice and staff anaesthetists

Generating a learning curve for the Bonfils Intubation Fiberscope. A pilot study evaluating the difference between novice and staff anaesthetists