A technique to facilitate laryngeal passage during flexible bronchoscopic intubation
KeywordsEpidural Catheter Flexible Bronchoscope Neck Position Laryngeal Inlet Lingual Traction
To the Editor,
Flexible bronchoscope (FOB)-assisted endotracheal intubation has a well-established role in airway management. Intubation with a FOB involves two steps: first inserting the bronchoscope into the trachea and then advancing an endotracheal tube (ETT) over the FOB. Nevertheless, when advancing the ETT over the FOB, the bevelled tip of the ETT can impinge on the vocal cords, arytenoids, or other hypopharyngeal structures and impede advancement through the laryngeal inlet.1,2
To overcome this hindrance, a common maneuver involves withdrawing, rotating (anticlockwise), and repeatedly advancing the ETT, as well as altering the patient’s head or neck position, external laryngeal manipulation, jaw-thrust maneuvers, and lingual traction.3 All of these measures may provide better alignment of the ETT and FOB with the laryngeal opening. Moreover, some specialized products (e.g., Aintree intubation catheter, tapered ETTs, Parker Flex-Tip® ETT) have also been used to minimize the gap between the FOB and the leading edge of the ETT, thus facilitating railroading of the ETT over the FOB. A limitation of the above devices is the necessity for them to be in place prior to the start of the intubation sequence. Furthermore, the efficacy of these various products has been debated,4 and their availability is somewhat variable.
The epidural catheter offers advantages as it is soft and smooth and thus minimizes the chances that it might damage tissues. The rigidity of the catheter also enables it to pass easily through the ETT lumen. If the catheter breaks, it can easily be removed as both ends are visible at the ETT connector.
Although the feasibility of this technique in all patients is unclear, it may offer an advantage as it can be accomplished without the need to remove the FOB. This will save time and limit the repeated attempts at passing the FOB. For those considering this approach in their airway armamentarium, practicing the technique beforehand in a simulator may offer an advantage. Further investigation will be required to confirm the broader safety and applicability of this technique.
This work did not require funding.
Conflicts of interest
VIDEO Video demonstrating the use of an epidural catheter looped through the Murphy eye of an endotracheal tube (ETT) to facilitate passage of the ETT through the vocal cords during flexible bronchoscopic intubation. (WMV 10488 kb)
- 4.Ho AM, Chunq DC, Karmakar MK. Is the Parker Flex-Tip tube really superior to the standard tube for fibreoptic orotracheal intubation? Anesthesiology 2003; 99: 1237.Google Scholar