1. Endotracheal intubation with flexible fiberoptic
bronchoscopy in patients with abnormal anatomic
conditions of the head and neck.
Publication: Ear, Nose and Throat Journal Online Format:
Publication Date: 01-NOV-07 Immediate Online Access
Delivery:
Full Article Title: Endotracheal intubation with flexible fiberoptic bronchoscopy in patients with
abnormal anatomic conditions of the head and neck.(Clinical report)
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Article Excerpt
Abstract
We performed a retrospective chart review to evaluate the indications for endotracheal intubation via flexible fiberoptic
bronchoscopy in patients who were scheduled for surgery or who were hospitalized in the intensive care unit of our 1,100-bed,
tertiary care university hospital. We reviewed 9,201 clinical records of anesthetic procedures during which endotracheal intubation
had been performed from January to December 2002. We identified 66 patients who had been intubated with flexible fiberoptic
bronchoscopy. On preanesthetic examination, 61 of these patients had been found to be poor candidates for conventional
laryngoscopic intubation--51 because of abnormal head and neck anatomy and 10 because of reduced visual access to the airway
(Mallampati class IV). The remaining 5 patients were intubated via flexible fiberoptic bronchoscopy after con ventional intubation had
failed during emergency surgery. Our study emphasizes (1) the importance of the preanesthetic examination of surgical patients, to
identify those in whom conventional intubation would likely be problematic, and (2) the need to have fiberoptic bronchoscopes and
an anesthesiologist or bronchoscopist skilled in their use available in operating suites and intensive care units.
Introduction
Endotracheal intubation for general anesthesia is usually performed with conventional (direct) laryngoscopy, (1-4) but at times
introducing an endotracheal tube is difficult. (5) In these cases, the patient cannot be well oxygenated, and severe hypoxemia and
even hypercapnia can occur, with a high risk of death. (6,7) Rogers and Benumof have identified a number of airway problems that
make tracheal intubation very difficult and/or dangerous. (8)
Endotracheal intubation via flexible fiberoptic bronchoscopy (FFB) can be performed when intubation via direct laryngoscopy is
impossible or when it is expected to be problematic. Failed intubation via direct laryngoscopy may, in fact, necessitate emergency
FFB intubation.
Difficult intubation by direct laryngoscopy can be predicted in patients with abnormal anatomic features. (9,10) Therefore, the upper
airways should always be examined preoperatively to detect such abnormalities as temporomandibular ankylosis, cervical spine
abnormalities, and congenital malformations of the mandible and larynx. (11) FFB-guided intubation can be performed with topical
or general anesthesia.
A system for evaluating the oropharynx, devised by Mallampati et al in 1985, identifies four classes of patients. (12) In Mallampati
class I, the soft palate, faucial pillars, and uvula are easily seen; in class II, the same structures are seen, but the uvula is masked
by the base of the tongue; in class III, only the soft palate can be visualized; and in class IV, only the hard palate that is in contact
with the tongue can be seen. (12) Patients in classes III and IV are candidates for FFB intubation.
Other authors have also addressed the problem of difficult intubation. (13-16) The multivariate airway risk index with logistic
regression, for example, proposed by el-Ganzouri et al, (16) accurately predicts possible intubation failures. Their approach takes
into account conditions related to the airway, such as the mouth opening, thyromental distance, oropharyngeal (Mallampati)
classification, neck mobility, ability to advance the lower jaw, body weight, and a history of difficult tracheal intubation. (16) The
authors detected poor conditions for tracheal intubation in 107 (1%) and poor mask ventilation in 8 (0.07%) of 10,507 cases
studied.
Researchers have found that it is easier to place an endotracheal tube with a video-assisted fiberoptic technique. (17-19)
Endotracheal intubation may also be difficult in patients in intensive care, and FFB-guided intubation is sometimes indicated in these
patients. (20,21)
Patients and methods

2. Our objective was to evaluate the indications for tracheal FFB-guided intubation (performed by the Departments of Anesthesiology
and Pneumology) in patients who were scheduled for surgery or who were hospitalized in the intensive care unit of a 1,100-bed,
tertiary care university hospital. Of 9,201 patients undergoing general anesthesia from January to December 2002, the charts of all
patients subjected to FFB endotracheal intubation were studied. Age, gender, diagnosis, type of anesthesia, French (Fr)
endotracheal tube size (range: 5.5 to 7.0 Fr), and secondary complications of the procedure were recorded.
Intubations were performed with a Pentax FFB and monitored with Sony Corporation's Image Management System, as described by
Prakash, (11) by an anesthesia team trained in the use of FFB intubation. The endotracheal tube was placed over the FFB and
introduced directly through the glottis into the trachea. Proper oxygenation was administered to the patient by means of an adaptor.
From the 9,201 anesthetic procedures reviewed, we selected 66 (0.72%) surgical patients for our study in whom intubation with FFB
had been performed: 27 (41%) were males and 39 (59%) were females. Average age was 32.9 years (range: 16 to 72 years).
FFB intubations were carried out under general anesthesia in 46 cases (69.7%) and with lidocaine topical anesthesia in 20 (30.3%)
awake patients (p [less than or equal to] 0.05, CI 95%). The bronchoscope was introduced perorally in 40 patients (60.6%) and
transnasally in 26 (39.4%) patients.
Results
The table shows the reasons for the use of FFB intubation in our 66 study patients. In 10 of 66 patients (15.2%), the airways had
been classified preoperatively as Mallampati class IV. In 51 cases (77.3%), the preoperative identification of abnormal anatomic
conditions was considered to be a sufficient reason for the patient to be intubated via FFB. Abnormal anatomic conditions included
temporomaxillary ankylosis (n = 9), maxillofacial ankylosis (n = 9), cervical spine abnormality (rigid neck; n = 4), thyroid tumor (n =
3), giant goiter (n = 3), laryngeal malformation (n = 3), Le Fort II fractures of the maxilla (n = 3), submandibular abscess (n = 3),
parapahryngeal abscess (n = 3), and miscellaneous pathologic conditions (16). Five of the patients (7.6%) presented as emergency
cases and had no preoperative evaluation of their airways. These patients required FFB intubation because attempts at direct
laryngoscopy during surgery had failed.
Discussion
Tracheal intubation with FFB is a well-known technique. Proper preanesthetic evaluation of the airway and the patient's head and
neck anatomy is necessary to determine whether a patient can be intubated via direct laryngoscopy or if that patient is a better
candidate for FFB-guided intubation. (7,12,15,16,20-22) Gentle, fast, and successful tracheal intubation is a particular challenge in
patients who have experienced facial and neck trauma (22) and in those with a rigid neck, a large tongue, or morbid obesity; in
these patients, nasotracheal intubation with FFB can be performed with topical anesthesia. Special masks and tubes may also be
required to properly...