Endotracheal intubation with flexible fiberopticbronchoscopy in patients with abnormal anatomicconditions 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 withabnormal anatomic conditions of the head and neck.(Clinical report)Ads by GoogleKey Switch Search Thousands of Catalogs for Key Switch www.globalspec.comEastmed Enterprises, Inc. Solutions for Laryngoscope needs Laryngoscope blades, handles,lamps www.discountlaryngoscope.comThe Most Cited IM Journal Annals of Internal Medicine View Our Special Offer! www.acponline.orgArticle ExcerptAbstractWe performed a retrospective chart review to evaluate the indications for endotracheal intubation via flexible fiberopticbronchoscopy 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 intubationhad been performed from January to December 2002. We identified 66 patients who had been intubated with flexible fiberopticbronchoscopy. On preanesthetic examination, 61 of these patients had been found to be poor candidates for conventionallaryngoscopic 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 hadfailed during emergency surgery. Our study emphasizes (1) the importance of the preanesthetic examination of surgical patients, toidentify those in whom conventional intubation would likely be problematic, and (2) the need to have fiberoptic bronchoscopes andan anesthesiologist or bronchoscopist skilled in their use available in operating suites and intensive care units.IntroductionEndotracheal intubation for general anesthesia is usually performed with conventional (direct) laryngoscopy, (1-4) but at timesintroducing an endotracheal tube is difficult. (5) In these cases, the patient cannot be well oxygenated, and severe hypoxemia andeven hypercapnia can occur, with a high risk of death. (6,7) Rogers and Benumof have identified a number of airway problems thatmake tracheal intubation very difficult and/or dangerous. (8)Endotracheal intubation via flexible fiberoptic bronchoscopy (FFB) can be performed when intubation via direct laryngoscopy isimpossible or when it is expected to be problematic. Failed intubation via direct laryngoscopy may, in fact, necessitate emergencyFFB intubation.Difficult intubation by direct laryngoscopy can be predicted in patients with abnormal anatomic features. (9,10) Therefore, the upperairways should always be examined preoperatively to detect such abnormalities as temporomandibular ankylosis, cervical spineabnormalities, and congenital malformations of the mandible and larynx. (11) FFB-guided intubation can be performed with topicalor general anesthesia.A system for evaluating the oropharynx, devised by Mallampati et al in 1985, identifies four classes of patients. (12) In Mallampaticlass I, the soft palate, faucial pillars, and uvula are easily seen; in class II, the same structures are seen, but the uvula is maskedby 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 contactwith 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 logisticregression, for example, proposed by el-Ganzouri et al, (16) accurately predicts possible intubation failures. Their approach takesinto 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) Theauthors detected poor conditions for tracheal intubation in 107 (1%) and poor mask ventilation in 8 (0.07%) of 10,507 casesstudied.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 thesepatients. (20,21)Patients and methods
Our objective was to evaluate the indications for tracheal FFB-guided intubation (performed by the Departments of Anesthesiologyand 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 allpatients 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 Corporations Image Management System, as described byPrakash, (11) by an anesthesia team trained in the use of FFB intubation. The endotracheal tube was placed over the FFB andintroduced 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 FFBhad 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%) andtransnasally in 26 (39.4%) patients.ResultsThe table shows the reasons for the use of FFB intubation in our 66 study patients. In 10 of 66 patients (15.2%), the airways hadbeen classified preoperatively as Mallampati class IV. In 51 cases (77.3%), the preoperative identification of abnormal anatomicconditions was considered to be a sufficient reason for the patient to be intubated via FFB. Abnormal anatomic conditions includedtemporomaxillary 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 emergencycases and had no preoperative evaluation of their airways. These patients required FFB intubation because attempts at directlaryngoscopy during surgery had failed.DiscussionTracheal intubation with FFB is a well-known technique. Proper preanesthetic evaluation of the airway and the patients head andneck anatomy is necessary to determine whether a patient can be intubated via direct laryngoscopy or if that patient is a bettercandidate for FFB-guided intubation. (7,12,15,16,20-22) Gentle, fast, and successful tracheal intubation is a particular challenge inpatients who have experienced facial and neck trauma (22) and in those with a rigid neck, a large tongue, or morbid obesity; inthese patients, nasotracheal intubation with FFB can be performed with topical anesthesia. Special masks and tubes may also berequired to properly...