Fiberoptic Assistance

The flexible fiberoptic laryngoscope or bronchoscope can be a valuable adjunct when there are anatomic or traumatic limitations that prevent visualization of the vocal cords. Clinical examples include conditions that prevent opening or movement of the mandible, congenital anatomic abnormalities, and cervical spine immobility.

These instruments allow visualization of laryngeal structures and can enable difficult intubations, including those around expanding hematomas ( Fig 15:;3). Patients in need of an immediate airway or those with ongoing hemorrhage or copious secretions are poor candidates.

Directed transoral or transnasal and translaryngeal topical anesthesia is essential. The nasal mucosa should be sprayed with a vasoconstrictor. Dual suctioning capability is needed; a suction port should be attached to a suction apparatus for oral blood and secretions. Tongue extrusion and anterior mandibular displacement will be helpful if the oral route is chosen. Fragile equipment is more frequently damaged transorally. The nasal route is better also because the optic tip can enter the glottis at a less acute angle.

Begin by focusing the eyepiece and lubricating the flexible shaft. Then immerse the lens at the tip of the laryngoscope in warm water to prevent fogging. The intubator should continuously monitor pulse oximetry and assure that the gag reflex is not present. After attachment of oxygen tubing to the suction port, intermittent insufflation of oxygen at 10 to 15 L/min to keep the optic tip clear should be considered. Insufflation is usually superior to suction for clearing secretions.

Initially remove the adapter from an ET tube that is at least 7.0 mm (ID) in size. To prevent barotrauma when high-flow oxygen is insufflated, use at least a 7.5-mm (ID) tube. Then slip the lubricated ET tube over the shaft up to the handle. The distal end of the laryngoscope must extend beyond the end of the ET tube. The laryngoscope is held with your left hand, and tip deflection is controlled while advancing it through the cords. The laryngoscope will function as a stylet for the tube. After the laryngoscope is in the trachea, advance the ET tube and remove the laryngoscope.

Another option is to insert a nasotracheal tube blindly into the posterior pharynx and stop about 1 to 2 cm proximal to the epiglottis. The scope is then inserted through this hollow conduit and the fiberoptic tip can be directed into the glottis. Be careful not to pass the lubricated scope through Murphy's eye. If this occurs, it will be impossible to advance the ET tube.

The fiberoptic scope cannot be used as a stylet to guide the ET tube into the trachea. The stiffer ET tube will often deflect the thin scope tip posteriorly into the esophagus. In addition, this keeps the concavity of the ET tube anterior toward 12 o'clock and places the tube tip and Murphy's eye at 3 o'clock (90° to the right). The tip will then often hit the right arytenoid cartilage. Rotating the tube 90° counterclockwise lines up the tip with the upper triangular entrance into the trachea.

Fiberoptic ET tubes are also commercially available. Direct line of sight can improve visualization in many difficult intubations. The advantages of direct vision include verification of tube positioning, identification of the right- or left-sided source of pulmonary hemorrhage, and inspection of tracheal injury.

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