Fibreoptic Bronchoscopic Intubation Research Articles

An Association of Predicted/Unpredicted Difficult Intubation with Fibreoptic Bronchoscopic Intubation

Aim: Inadequate preoperative airway assessment is one of the most common causes of failed airway management and intubation. Fibreoptic bronchoscopic intubation (FBI) is an effective technique for creating airway access in patients with expected and unexpected difficult airways. The aim of this study is to evaluate the incidence of predicted difficult airway (DA) in patients intubated due to DA with FBI.
 Materials and Methods: We retrospectively reviewed the medical records of one hundred and forty-three ASA I-V patients aged 0-80 years diagnosed with DA who underwent flexible FBI from January 2006 to December 2011. Age, weight, sex, concomitant syndromes, whether difficult intubation (DI) occurred after trauma, whether FBI was applied via nasal or oral ways, size of tube, whether FBI was successful or not and relationships of these parameters were analysed.
 Results: The study involved 143 patients, 38 (22.2%) in the pediatric group and 105 patients (77.8%) in the adult group. Of the patients, 64 (47.4%) were female and 71 (52.6%) were male. 42 patients underwent DI for syndromes with craniofacial abnormalities. As a result of preoperative anaesthetic assessment, DI could be predicted in 74 patients (51.7%) by history, physical examination and Mallampati scoring, while unexpected DI occurred in 69 (48.3%) of patients. The proportion of predicted DA was much higher in children compared to adults.
 Conclusion: It is not easy to check all predictors of DI in a pre-anaesthetic examination and the predictors are not accurate. Unexpected DI is not a rare occurrence in the operating room (OR). Despite a thorough pre-operative assessment, anaesthetists may not be able to predict what they will encounter during surgery and therefore should always be prepared for any challenge.
 Keywords: Preoperative assessment, predicted difficult intubation, fiberoptik bronchoscopic intubation, syndromes with craniofacial abnormalities

Supraglottic jet oxygenation and ventilation-assisted fibre-optic bronchoscope intubation in patients with difficult airways

A difficult airway may lead to hypoxia and brain damage. The WEI Nasal Jet Tube (WNJ) is a new nasal pharyngeal tube that applies supraglottic jet oxygenation and ventilation (SJOV) for patients during tracheal intubation without the need for mask ventilation. We evaluated the effectiveness and safety of SJOV-assisted fibre-optic bronchoscopy (FOB) using the WNJ in the management of difficult tracheal intubations. A total of 50 adult patients with Cormack-Lehane grade ≥3 and general anesthesia with tracheal intubation were randomly assigned to either the laryngeal mask airway (LMA) or WNJ groups. The primary outcome was the percentage of patients with SpO2 values lower than 94% during intubation. The proportion of successful intubations, total time of intubation, and associated complications were also recorded. The percentage of patients with SpO2 values lower than 94% during intubation was significantly higher in the LMA group (25% in the LMA vs. 0% in the WNJ, P=0.01). Although there were no statistically significant differences in the total success rates of intubation, the first-attempt success rate was significantly higher in the WNJ group (100 vs. 79.2%, P=0.02). The total time required for intubation with the WNJ was shorter than that of the LMA (73.4 vs. 99.5s, P<0.001), although the duration of fibre-optic intubation was similar. The incidence of complications was similar between the two groups. SJOV-assisted FOB using the WNJ improved oxygenation and successful tracheal intubation in the management of difficult airways. This technique can be used as an alternative approach to improve success and minimize hypoxia during difficult airway management.

Nasotracheal intubation by combined use of a Bullard™ laryngoscope and a cuff inflation technique in a patient with a severely restricted mouth opening

To the Editor, The Bullard laryngoscope (Circon ACMI, Stamford, CT, USA) is an anatomically shaped rigid fibreoptic laryngoscope that has been used for more than two decades. One of its unique characteristics is a very thin blade that requires only a 6-mm mouth opening for insertion. We report a case in which nasotracheal intubation was performed by combined use of a Bullard laryngoscope and a cuff inflation technique in a patient with a severely restricted mouth opening. The patient provided written informed consent for publication of this case. A 66-yr-old male patient, 157 cm tall and weighing 45.5 kg, was scheduled for keratoplasty. The size of his mouth opening was only about 9.5 mm because of previous radiation therapy for maxillary sinus cancer; thus, nasotracheal intubation was planned for airway management. The Bullard laryngoscope was selected for this procedure instead of a fibrescope because with the fibrescope, the tracheal tube is advanced in a blind manner and this may cause airway trauma; arytenoid cartilage dislocation or vocal cord trauma. General anesthesia was induced with fentanyl 150 lg and propofol 30 mg. Bag and mask ventilation was performed successfully, and then rocuronium 40 mg and remifentanil 0.3 lg kg min were administered. Even after neuromuscular blockade, no additional mouth opening was obtained. A 7.5-mm internal diameter tracheal tube was inserted nasally, and the Bullard laryngoscope was inserted orally to lift the epiglottis directly. A laryngeal view was easily obtained through the eyepiece of the Bullard laryngoscope, and then the tracheal tube was advanced carefully into the field of view. Before the laryngeal inlet was reached, the tracheal tube cuff was inflated to lift the tube tip and direct it towards the vocal cords. The cuff was then deflated to pass through the vocal cords. The tracheal tube was successfully inserted into the trachea, and general anesthesia was maintained throughout the operation without any complications. Also, no complications were encountered during postanesthesia rounds. In the past several years, anatomically shaped indirect laryngoscopes with a tracheal tube guide channel, such as the Pentax Airway Scope (HOYA, Tokyo, Japan) and the Airtraq (Prodol Meditec SA, Vizcaya, Spain), have become very popular and have been reported to be useful in airway management. Although several studies have shown that the Airway Scope and Airtraq are more useful than the Bullard laryngoscope for orotracheal intubation and even for nasotracheal intubation, these laryngoscopes have a bulky blade configuration because the tube channel is thicker than the tube diameter (Figure). Even the version of the Airtraq designed for nasotracheal intubation, which is devoid of a tube guide channel, requires an 18-mm mouth opening for insertion; therefore, in our case, the thinner blade of the Bullard laryngoscope was adequate to obtain a laryngeal view. The alternative approaches we could have considered in our case include a fibreoptic bronchoscopic intubation or a lightwandguided technique through the nostril. However, both techniques involve tracheal tube advancement in a blind manner, which may cause trauma, particularly to the arytenoid cartilage or vocal cords. A Bullard laryngoscope-assisted nasotracheal intubation can be a useful approach in patients with a severely restricted mouth opening because it provides a good laryngeal view and continuous observation of tube insertion throughout the procedure. A. Tampo, MD, PhD (&) A. Suzuki, MD, PhD M. Matsumoto, MD H. Iwasaki, MD, PhD Asahikawa Medical University, Asahikawa, Hokkaido, Japan e-mail: atampo1031@gmail.com

Awake light-aided blind nasal intubation: prototype device

Limited mouth opening associated with unavailable or ineffective fibreoptic bronchoscope (FOB) is an intubation challenge. A light-aiding device may facilitate the blind nasal intubation. Awake blind nasal intubation was planned for 16 elective patients with inaccessible oral route (three children and 13 adults, ASA I-II). Topical anaesthesia for the supraglottis, glottis, and upper trachea was performed using prototype supraglottic topical anaesthesia device and cricothyroid injection of local anaesthesia. Hand-made light-aiding intubation device was used to help blind nasal intubation. Three attempts of blind nasal intubation (60 s each) were allowed, otherwise failure and FOB intubation were considered. During the procedure, heart rate, mean arterial pressure, and arterial oxygen saturation (Spa(o(2))) were measured. Temperature created at the bulb surface of the device was measured for 4 min duration, with and without exposing the bulb to oxygen flow of 6 litre min(-1). All the patients were successfully intubated except one child. Time to intubate in adults was mean (sd) 52.7 (8.6) s. Spa(o(2)) showed significant difference between before and after procedural values. The maximum temperature recorded at the bulb surface was 46.8 (0.4) degrees C and 48.1 (0.8) degrees C with and without oxygen flow, respectively. The device appeared to be a safe and cost-effective transillumination method for blind nasal intubation in difficult airways.

Personal protection equipment for biological hazards: Does it affect tracheal intubation performance?

SummaryPurposePersonal protection equipment (PPE) is recommended for use during airway management of patients with highly contagious respiratory tract illness. While its use in chemical hazards and its effect on airway management has been assessed previously, there has been no research assessing whether this equipment affects the ability to perform tracheal intubation. It is the intention of this investigation to answer this question.MethodsEighteen workers at various level of training were asked to wear three different types of PPE while performing four different types of tracheal intubation. The PPE used included the eye shield, face shield and the “Dustmaster™”. The intubation techniques were direct laryngoscopy, intubation through the intubating laryngeal mask (Fastrach™) and flexible bronchoscopy using the eyepiece and an eyepiece with camera attached. We assessed the time to intubate as well as the incidence of oesophageal intubation. A short questionnaire was used to examine participants’ subjective experiences of wearing the various types of PPE.ResultsThere was no significant effect on the time to intubation for any of the methods studied. However, all subjects found that the face shield was uncomfortably hot to wear. Fibreoptic bronchoscopic intubation using the eyepiece was particularly difficult with all of the PPE used due to the distance of the subjects’ eye from the eyepiece.ConclusionAlthough the use of PPE may not affect the length of time to intubate manikins, certain types of PPE may be uncomfortable to wear and noisy. Further research is needed to investigate whether this could be a problem in the clinical setting or in actual difficult intubations.

Fibre-optic intubation in oncological head and neck emergencies

Although fibre-optic bronchoscopic intubation is well recognized as the most valuable adjunct for elective management of the difficult airway its precise role in oncological head and neck emergencies has not been evaluated. The objective of this study was to evaluate the role of fibre-optic intubation in such emergencies. This was a consecutive case series study by a single surgeon (the otolaryngologist) and anaesthetist team, taking place in a regional tertiary-referral head and neck surgical oncology centre. A series of 17 consecutive oncological head and neck emergency patients underwent fibre-optic intubation with a Portex endotracheal tube of inner diameter > or =7 mm, with the aid of a 6-mm (EB-1830T2) Pentax fibre-optic video bronchoscope. The study assessed occurrence of: avoidance of tracheostomy in bleeding emergencies; a well placed, uncomplicated tracheostomy in airway obstruction; and successful intubation. Two cases were decannulated completely. All cases were successfully intubated and a tracheostomy was avoided in all cases in which emergency intubation was required and the patient was bleeding. We conclude that fibre-optic bronchoscopic intubation is a viable option in head and neck oncological emergencies due to upper airway obstruction and tumour bleeding. Clinical and endoscopic judgement and operator experience are the key factors determining success.

Thyroid surgery and anaesthesia following head and neck irradiation for childhood malignancy.

Increasing numbers of adolescents and young adults are undergoing thyroid surgery because of the risk of malignancy following previous irradiation for childhood malignancy. Irradiation to the head and/or neck regions may induce changes in the soft tissues and larynx that are far from normal with respect to both size and mobility. The aim of the present study was to evaluate the possible impact of such changes on both surgical and anaesthetic technique during thyroidectomy. This was a retrospective ease study. Thirty consecutive patients undergoing total thyroidectomy following previous irradiation for childhood malignancy formed the study group. There were no permanent surgical or anaesthetic complications in the group. In particular there were no cases of either permanent recurrent laryngeal nerve palsy or permanent hypoparathyroidism. Twenty-eight patients had an uneventful intubation and two were unable to be intubated directly, one requiring fibre-optic bronchoscopic intubation and the other having surgery performed with a laryngeal mask following failed bronchoscopy. Both of these patients had received high-dose direct irradiation to the larynx for solid tumours. Despite potential difficulties associated with the heavily irradiated larynx, thyroid surgery and anaesthesia can be performed safely with minimal complications in experienced hands.

Physiological factors limiting work tolerance in chemical protective clothing : G. Smith, P. Bishop, J. Beaird, P. Ray, J. Smith, International Journal of Industrial Ergonomics, 13 (1994) 147–155

Personal protection equipment (PPE) is recommended for use during airway management of patients with highly contagious respiratory tract illness. While its use in chemical hazards and its effect on airway management has been assessed previously, there has been no research assessing whether this equipment affects the ability to perform tracheal intubation. It is the intention of this investigation to answer this question.Eighteen workers at various level of training were asked to wear three different types of PPE while performing four different types of tracheal intubation. The PPE used included the eye shield, face shield and the “Dustmaster™”. The intubation techniques were direct laryngoscopy, intubation through the intubating laryngeal mask (Fastrach™) and flexible bronchoscopy using the eyepiece and an eyepiece with camera attached. We assessed the time to intubate as well as the incidence of oesophageal intubation. A short questionnaire was used to examine participants’ subjective experiences of wearing the various types of PPE.There was no significant effect on the time to intubation for any of the methods studied. However, all subjects found that the face shield was uncomfortably hot to wear. Fibreoptic bronchoscopic intubation using the eyepiece was particularly difficult with all of the PPE used due to the distance of the subjects’ eye from the eyepiece.Although the use of PPE may not affect the length of time to intubate manikins, certain types of PPE may be uncomfortable to wear and noisy. Further research is needed to investigate whether this could be a problem in the clinical setting or in actual difficult intubations.

Fibreoptic bronchoscopic intubation after induction of general anaesthesia: another approach

Fibreoptic bronchoscopic intubation after induction of general anaesthesia: another approach