Fiberoptic intubation.Presenter: DR.TREVOR. Moderator:

DR.RANJAN

Indications for fibreoptic intubation

Definitive history or anticipated difficult intubation

Known or suspected cervical spinal injury or disease

? failed intubation ~ may be difficult if trauma

Congenital airway abnormalities.

Indications for fibreoptic airway endoscopy

Airway evaluation Investigation of stridor Assessment of laryngotracheal injury

eg. Trauma, prolonged endotracheal intubation

Tracheobronchial toilet. Foreign body removal.

Endotracheal tube manipulation

Verification of endotracheal tube positioning. [single/double lumen]

Endobronchial intubation. Evaluation of endotracheal

obstruction. Endotracheal tube change. Tracheal extubation.

The “Open it up, line it up” FIBEROPTIC INTUBATION  

1. Choose the appropriate fiberoptic intubation mode Anesthetized or awake.

Oral or nasal

Indications for awake fiberoptic intubation. Trauma :Upper airway, Cervical spine , Face. Congenital airway abnormalities. Definitive history of difficult

intubation. Anticipated difficult intubation: Micrognathia. Short muscular or obese neck. Decrease temperomandibular joint range of

movement. Prominent buck teeth

2.Prepare the awake patient.“difference between success and

failure.”

Preoperative explanation of the indication and procedure by the consultant anesthesiologist.

8 hours pre operative fasting –elective. Dry the airway!!!-vagolytic agent. Atropine/ glycopyrrolate :preferably

intramuscular 1 hour before the procedure. Avoid sedative pre medication in the pre

operative holding area.

Once in o.t…. Venous access. Baseline monitors: E.C.G,

pulseoximetry, N.I.B.P. Judicious use of sedatives, to keep the

patient amnesic, yet co-operative, with spontaneous respiration.

Small incremental doses to desired effect

Narcotics, benzodiazepines .

Topical Anesthesia of the Airway.

Nasal Passage Oropharynx Larynx and Trachea. “proper airway anesthesia is

essential to a successful awake fiberoptic intubation”

Sensory innervation of upper airway segments.

Nasal passage Medial & lateral: ant ethmoidal

branch of nasociliary nerve Floor: superior dental nerve Posterior: long & short

sphenopalatine nerve from sphenopalatine ganglion

Preparation for nasal route.

Cocaine – 5% or 10%

Max safety dose; 3mg/kg Applied with

pledgets @ cotton-tipped

Advance till reach posterior wall of nasopharynx

Left for 5 minutes

0.05% oxymetazoline

Instilled into both nostrils,15 min intervals.

Followed by 3-4 sprays of 10% lignocaine or 1 ml 4% lignocaine via atomizer

Application of nasal pledgets.

Anesthesia for the nares.

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

Atomizer.

Atomization is conversion of bulk liquid into a spray or mist (i.e. collection of drops), often by passing the liquid through a nozzle .

An atomizer is an atomization apparatus;

Atomizer.

Enk Fiberoptic Atomizer Sets provides topical anesthesia by atomizing

small doses of local anesthetics through the working channel of the bronchoscope using flow oxygen.

Reduced doses of anesthetics together with the atomizer effect enhance patient comfort.

Repeated administration of local anesthetic solutions and flow oxygen (“spray as you go”) keeps the front lens clear during bronchoscope advancement.

Enk Fiberoptic Atomizer Sets

Pharynx (divided into naso, oro & laryngopharynx)

• Nerve supply: mainly branches of glossopharyngeal & vagus nerve

Anesthesia of oral cavity & pharynx-noninvasive.

10% solution of lignocaine

Sprayed at tongue, fauces, soft palate, uvula & posterior oropharyngeal wall

Protrude tongue; sprayed lateral & posterior laryngopharyngeal wall

Approximate; 4-5 metered sprays

Viscous lignocaine 4% or 4% lignocaine

Gargle (swish & swallow)

2-3 mls of 4% lignocaine; sprayed from oropharynx down to and through vocal cords with an atomizer

Nebulized lidocaine. Place 5 ml of 4% lidocaine into a

nebulizer, flow oxygen through the nebulizer and channel the nebulized lidocaine through a face mask.

Highly effective. Disadvantages: Time consuming. High risk of systemic toxicity.

Invasive- GLOSSOPHARYNGEAL NERVE 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.

GLOSSOPHARYNGEAL NERVE BLOCK.

Sensory innervation .

Larynx. Above vocal cord: internal branch

of superior laryngeal nerve (from inferior ganglion of vagus)

Below vocal cord: recurrent laryngeal nerve.

Trachea: vagus.

Vagus nerve branching into Superior Laryngeal and Recurrent Laryngeal nerve.

Note the insertion of Superior Laryngeal Nerve into ThyroHyoid Membrane.

 

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

superior laryngeal nerve block-noninvasive. Less common procedure. Patient is asked to open the mouth

widely, and the tongue is grasped using a guaze pad or tongue blade.

A right angle forcep (e.g., Jackson-Krause) is covered with anesthetic-soaked guaze and is slid over the lateral tongue and down into the pyriform sinuses bilaterally.

Cotton swabs are held in place for 5 minutes.

superior laryngeal nerve-invasive.

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

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.

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

Technique Tips! Exercise 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.

TRANSTRACHEAL BLOCK.

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 .

Placement of fingers to identify the midline of the cricothyroid membrane .

A 10 ml syringe containing lidocaine is mounted on a 22-guage, 35 mm plastic catheter over a needle, and is introduced into the trachea.

The catheter is advanced into the lumen, midline thru the cricothyroid membrane, at an angle of 45 degrees, in a caudal direction.

Placement of the needle for the Transtracheal block.

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.

This will usually cause patient to first inhale to catch his or her breath and then forcefully cough, spreading the lidocaine over the trachea, making distal airway anesthesia more predictable.

Transtracheal spread of local anesthetic with coughing.

Complications:

Systemic toxicity . Vascular injury . Structural injuries . Gastric Aspiration

Open up the airway.

Devices to Aid Intubation.1.Intubating Airways: oral.Olympus bite block.Williams airway.Ovassapian airway.Nasal Airway.2.Intubation via endoscopy mask. Patil mask.

Intubating oral airways.

Prevent trauma to the fiberscope from the patients teeth.

[expensive piece of equipment] Guide to the fiberscope to position

it in midline towards the glottic opening.

Olympus bite block.

Advantages. Commonly available. Large internal diameter: possible

to use variety of sizes of endotracheal tube.

Short length: comfortable for use in an awake patient.

olympus bite block.

Disadvantages.

Not a useful guide for the fiberscope.

Endotracheal tube to Y piece connector must be removed, while mounting:

Chances of tube dislodgement while removing bite block.

Williams airway.

Longer piece serves as a better guide to the fiberscope.

Disadvantages; Longer piece: increases likelihood of

tube dislodgement. Not comfortable to an awake

patient.

Williams airway

Ovassapian airway.

Resembles the williams airway in length and curvature: similar problems.

Advantage: Dorsal openings allowing it to be

removed without sliding over the tube.

Ovassapian airway

Fiberscopy via an oral airway.

Patil mask.

Adapter through which the fiberoptic laryngoscope and endotracheal tube may be introduced.

Mask permits ventilation of the patient during the intubation process.

Patil mask :

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.

3.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 .

Connect the light source. Focus is adjusted. Suction tubing is connected. three way connected to the working

channel,through which oxygen or lignocaine can be administered.

Lubricate the fiberoptic shaft with a small amount of silicone gel. Dab a bit of defogging solution on the shaft tip.

Choose an appropriate endotracheal tube.

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

Slide the endotracheal tube up the full length of the shaft and gently secured to the end of the bronchoscope handle.

Smear a little lubricant on the cuff and distal end of the endotracheal tube.

.

Fiberscope with endotracheal tube mounted .

Fiberscope with laryngeal mask airway mounted.

Line up the fiberoptic shaft . Know where that tip points before it disappears from view!

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. Position the shaft above the middle of the patient’s mouth or nose at 90 degrees to the horizontal.

Introducing the fiberscope

-The fiberscope is introduced through the nasal or oral route.

-scope is passed behind the soft palate and the tongue, epiglottis can be identified – advance scope & go under epiglottis to view vocal cords and glottis

View of the epiglottis through the fiberscope.

View through the fiberscope: glottic aperture

Happy sight of glottic aperture in a fiberscope.

Sad sight.

- 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 .

After passing through the vocal cords the fiberscope is advanced until the tracheal rings come into view. The carina should be easily identifiable in the distance.

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

left hand to loosen the endotracheal tube connector from the bronchoscope handle.

grasp the endotracheal tube at its midpoint and rotate it 90 degrees counterclockwise so the Murphy eye is anterior.

This maneuver prevents the tube tip from hanging up on the right arytenoid.

Advance the endotracheal tube into the trachea over the bronchoscope shaft until the 22-cm or 23-cm mark on the tube is at the teeth.

Confirm position of ETT before withdrawing the scope completely

Withdraw the fiberoptic shaft and secure 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.

fiberoptic shaft falls posteriorly into the interarytenoid fissure

Causes of Failure of Fibreoptic Intubation.

Lack of Experience Secretions and Blood Inadequate Topical Anesthesia Decreased Space Between

Epiglottis and Posterior Pharyngeal Wall.

Causes of Failure

Distorted Airway Anatomy Inability to Advance the ETT Inability to Remove the Fiberscope

Tips The fibrescope must always be kept as

straight as possible to maintain control over the tip - if it is allowed to become slack, tip control is lost.

Never advance the scope without being able to see through the scope where you are going - failure to obey this rule results in bleeding, an obscured field, and failure.

Tips If you can't see pull back. In awake patients always use a

bite block or airway, otherwise teeth will inflict irreversible damage upon your fiberscope!

As always ventilation trumps intubation - and problems, withdraw, ventilate the patient, and ask for senior assistance.

Complications.

Trauma related to iatrogenic factors, anatomy,

and diseases of the patient, or ETT and bronchoscope design.

Complications…

Adverse reactions to sedation. Respiratory depression Hypotension Syncope Hyper-excitable state

Complications…

Adverse reactions to local anesthetics. Respiratory arrest Seizures Cardiovascular collapse laryngospasm

Complications ~ related to procedure

Cardiovascular events: Dysrrhythmias Hyper,hypotens

io Myocardial

ischaemia Cardiac arrest

Respiratory events: Laryngospasm Bronchospasm Desaturation Pneumonia Aspiration