12:01 ص 1

Dr. Wesam Farid MousaAssisstant Professor Anesthesia & ICU

Dammam Hospital of the University

Basics of Fiberoptic Intubation

1897 First rigid bronchoscopy he removed a bone (113 mm) from right main stem bronchus

Gustav Killian, M.D.1860-1921 Mainz, Germany

Shigeto Ikeda, M.D.

First flexible fiberoptic bronchoscopy

Japan, 1966

• Definitive history or anticipated difficult intubation

• Known or suspected cervical spinal injury or disease

• ? failed intubation

Fiberoptic intubation modes

Anesthetized oralAnesthetized nasal

Awake oralAwake nasal

Discussion with the patient for:

Safety vs comfort

Feeling of inability to breath

Coughing

Chocking

Speech changes

Early signs of lidocaine toxicity

prepartion for awake fiberoptic intubation

12:01 ص 8

ASA monitors to be applied

12:01 ص 9

Sedation

Fentanyl and midazolam most widely used.

Dexmeditomidine, alfentanyl, remifentanyl and propofol are suitable alternatives

My dear: Anesthesiologist is sick today

12:01 ص 10

Take home message#1

The goal is to provide conscious sedation to afford comfort and amnesia

12:01 ص 11

Be ready for GA

Be ready for emergency airway

Be ready for systemic toxicity of local anesthesia

12:01 ص 12

Anesthesia of oral cavity & pharynx-

Non invasive: TopicalizationInvasive: Glossopharyngeal nerve block Anesthesia of the larynx: Above vocal cord:internal branch of superior laryngeal nerve Below vocal cord: recurrent laryngeal nerve.

Anesthesia of the trachea

Anesthesia of the airway

12:01 ص 13

A: TopicalizationLidocaine nebulization and atomization

Cotton-tipped swabs soaked in lidocaine left for several minutes in mouth or nose Spraying through the work channel of the scopeAlso we can use:

Lidocaine 5% ointmentLidocaine lollipop

Lidocaine 4% gargleEMLA cream

Anesthesia of the airway

Atomization is conversion of bulk liquid into a spray by passing the liquid through a nozzle.

• Place 5 ml of 4% lidocaine into a nebulizer,

• Highly effective. • risk of systemic toxicity.

10% solution of lignocaine Sprayed at tongue, fauces, soft palate, uvula & posterior

oropharyngeal wallProtrude tongue; sprayed lateral & posterior laryngopharyngeal

wallApproximate; 4-5 metered sprays

12:01 ص 14

glossopharyngeal block

easily accessed as they transverse the palatoglossal folds .A 25g needle is inserted into the membrane near the floor of the mouth at the anterior tonsillar pillar 0.5 cm lateral to the base of the tongue.advanced slightly (0.25-0.5 cm). 2 ml of 1% Lidocaine can be injected.

Anesthesia for the nares.

• Progressively larger sized soft nasal airways coated with 2% lidocaine.

Vagus nerve branching into Superior Laryngeal and Recurrent Laryngeal nerve.

Note the insertion of Superior Laryngeal Nerve into ThyroHyoid Membrane.

 

superior laryngeal block – larynx above the cords

Tracheal anatomy depicting Superior Laryngeal Nerve with the internal and external branch.

superior laryngeal block – larynx above the cords

requires neck extension.Identify the greater cornu of the hyoid bone and superior cornu of the thyroid cartilage.

Pressing the contralateral greater cornu of hyoid bone, laryngeal structure to be displaced towards the side to be blocked.

• At a depth of 1-2 cm, 2 ml of 2% lidocaine with epinephrine is injected into the space between the thyrohyoid membrane and the pharyngeal mucosa.

• The block is repeated on the other side

22 or 23 guage – 25 mm needle is "walked off" the cornu of the hyoid bone in an anterior caudad direction, aiming in the direction of the thyroid ligament, until it can be passed through the ligament.

Technique Tips!

• caution - not to insert the needle into the thyroid cartilage, since injection of local anesthetic at the level of vocal cords may cause edema and airway obstruction.

• If air is aspirated, laryngeal mucosa has been pierced, and the needle needs to be retrieved.

• If blood is aspirated (superior laryngeal artery or vein), the needle needs to be redirected more anteriorly. Pressure should be applied to avoid hematoma formation.

This is more correctly described as a method of topically applying local anesthetic to the trachea and larynx.

Translaryngeal “Transtracheal” block :– larynx and trachea below the cords

place index and third fingers of the non-dominant hand in the space between the thyroid and cricoid cartilages

The trachea can be held in place by placing the thumb and ring finger on either side of the thyroid cartilage. The midline should then be identified

• Immediately after the introduction of the catheter into the trachea, a loss of airway resistance and aspiration of air confirms placement, and the needle is removed from the catheter.

• The patient is then asked to take a deep breath and then asked to exhale forcefully

• At the end of the expiratory effort, 3-4 ml 2% lidocaine solution is rapidly injected into the trachea.

12:01 ص 23

Signs of effective airway anesthesia

Speech changes: difficulty getting words out, slurred speech, pitch changes, hoaseness

No gagging on deep touch to posterior third of the tongue and pharynx

12:01 ص 24

Take home message #2

Sedation will not compensate for poor topicalization

Setup the fiberoptic scope. “A place for everything and everything

in its place."• Place the bronchoscope and its cart on the

left side of the patient .

Open up the airway

Devices to Aid Fiberoptic Intubation. Intubation via Airways:

oral.o Olympus bite block.o Williams airway.o Ovassapian airway.

Nasal.

Intubation via Endoscopy Mask. Patil mask.

Intubating oral airways• Prevent trauma to the fiberscope from the

patients teeth.• Guide to the fiberscope to position it in midline

towards the glottic opening.

Olympus bite block

Advantages..

• Large internal diameter: possible to use variety of sizes of endotracheal tube.

• Short length: comfortable for use in an awake patient.

Disadvantages

• Not a useful guide for the fiberscope.

• Chances of tube dislodgement while removing bite block.

Williams airway

• Longer piece serves as a better guide to the fiberscope.

But

increases likelihood of tube dislodgement.

• Not comfortable to an awake patient.

Ovassapian airway

Same length & curvature as williams airway and : similar problems

Advantage: Dorsal openings allowing it to be removed without sliding over the tube.

Patil mask

• Adapter through which the fiberoptic is introduced.

• Mask permits non invasive ventilation of the patient during the intubation process.

12:01 ص 33

Push the tongue caudally with tongue depressor on middle of tongue: it will pop out.

Tongue pulling out

Open up the airway

12:01 ص 34

Hold the tongue with a gauze and pull it out

Tongue pulling out

12:01 ص 35

Pulling out tongue will elevate the epiglottis away from the posterior pharyngeal wall

Take home message #3

12:01 ص 36

1) Eye piece: Can be attached to a camera for display on screen

2)Diopter ring for focusing3)Control lever: Controls the tip4)Working channel port: For suction, instillation of local anesthetic, oxygen delivery.

5)Body: Incorporates the eye piece, diopter ring, control level and working channel. Grasped by the operators non-dominant hand.

6)Insertion cord: Contains fiberoptic bundle for light and image transmission7)Light source: Can be a portable battery powered

source or via a cable8)Suction valve and port

Anatomy of the bronchoscope

12:01 ص 37

Flexion lever moves tip of the scope from 06:00 to 12:00 in one plane

Tip at 06:00 position Tip at 12:00 position

12:01 ص 38

Flexion lever moves tip of the scope from 06:00 to 12:00 in one plane

12:01 ص 39

To flex the tip in other planes, rotate the entire scope

Fiberscope with endotracheal tube mounted .

Fiberscope with laryngeal mask airway mounted.

12:01 ص 42

Small tubes (6.0-6.5 mm for female patients and 7.0 mm for male patients) advance more easily.

The size discrepancy between the fiberoptic bronchoscope and the tracheal tube that has been threaded onto it can create a cleft that can entrap anterior anatomic structures, hindering advancement of the tracheal tube into the larynx (hang-up).

12:01 ص 43

Marker to be put at 12;00 to maintain spatial orientation

12:01 ص 44

Line up the fiberoptic shaft .

Know where that tip points before it disappears from view!

12:01 ص 45

As in laparoscopic surgery either at right or left of the patient depending on the dominant hand

Position of the anesthesiologist

12:01 ص 46

Position of the anesthesiologist

12:01 ص 47

Hand position

Dominant hand is put proximal to the patient and holds the scope as a pen

Stand on a lift so that the fiberoptic bronchoscope shaft will be straight when you hold it above the patient.

The head of the fiberscope is held in the right hand, with the right thumb on the control lever.

With your left hand, hold the bronchoscope shaft at a point 15 to 20 cm from the shaft tip.

(A) The handle is held in the nondominant hand with the tip of thumb over the sagittal plane control lever. The index finger can be used to control the working channel (e.g., suction, oxygen insufflation). The dominant hand is used for fine manipulation at the distal end. (B) The operator's two hands should be kept maximally apart so as to keep the insertion shaft as straight as possible, maximizing coronal plane rotational control. (C) Curves introduced along the shaft reduce coronal plane rotational control.

48

Handling of the fiberopticbronchoscope.

Patient positioning for fiberoptic intubation..

classical sniffing position:• Places the epiglottis against the posterior

pharyngeal wall, causing difficulty in maneuvering the fiberscope under the epiglottis.

Neutral position• The chin lift and jaw thrust maneuvers,

move the soft tissues and lifts the epiglottis from the posterior pharyngeal wall improving the view through the fiberscope.

12:01 ص 50

Defog the tip byDefogger

Warm waterAgainst buccal mucosa

12:01 ص 51

Pink color is seen if you position the scope against tongue suface

Now you are ready to go

12:01 ص 52

Flush with scope on the tongue in the midline towards the uvula

Uvula

Bottom of the tongue

- The patient is then asked to take a deep breath and the bronchoscope is passed through the cords.

-If this precipitates coughing, additional lidocaine can be sprayed through the working

channel of the bronchoscope .

12:01 ص 53

Keep the tongue in the botom half of the view by rotating the hand holding the tip of the scope

12:01 ص 54

Keep lumen of the airway centered

Keep tongue in view

12:01 ص 55

Once epiglottis is seen, ask the patient to take deep breath and ask the assisstant to thrust the jaw forward

This will move epiglottis anteriorly away from the posterior pharyngeal wall

12:01 ص 56

use the lever to flex or extend the distal end of the scope

Advance the scope into the trachea

12:01 ص 57

Determine the right and left main brochi

Do not touch the carina

• After passing through the vocal cords the fiberscope is advanced until the tracheal rings come into view and the carina becomes identifiable.

• When the tip of the fiberscope is at the carina, the next step is to pass the endotracheal tube.

• If the fiberscope passes through the vocal cords, but the endotracheal tube does not pass, the tube may be getting caught on the arytenoid cartilages. Rotating the endotracheal tube ninety degrees counterclockwise directs the tip into the trachea.

Happy sight

Sad sight.

CONTRAINDICATIONS TO FIBEROPTIC BRONCHOSCOPY 

1. Hypoxia

2. Heavy airway secretions not relieved with suction or antisialagogues

3. Bleeding from the upper or lower airway not relieved with suction

4. Local anesthetic allergy (for awake attempts)

5. Inability to cooperate (for awake attempts)

62

12:01 ص 63

Take home message

Center the lumen: by rotating the handle of the scope

Keep the tongue in view: Flex or extend the tip of the scope

Advance the tip of the scope with the index finger

12:01 ص