Fiberoptic intubation
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1) The document discusses the history and techniques of fiberoptic intubation. It began with the first rigid bronchoscopy in 1897 and the development of the flexible fiberoptic bronchoscope in 1966. 2) There are different modes of fiberoptic intubation including anesthetized oral, anesthetized nasal, awake oral, and awake nasal. Proper airway anesthesia and sedation techniques are important to prepare for awake fiberoptic intubation. 3) The document reviews techniques for fiberoptic intubation including how to open the airway, use various airway devices, handle the bronchoscope, advance the scope, and pass the endotracheal tube. It emphasizes the importance of proper setup
Fiberoptic intubation
- 1. : م1 2051 م 1 Dr. Wesam Farid Mousa Assisstant Professor Anesthesia & ICU Dammam Hospital of the University
- 2. Basics of Fiberoptic Intubation
- 3. 1897 First rigid bronchoscopy he removed a bone (11Χ3 mm) from right main stem bronchus Gustav Killian, M.D. 1860-1921 Mainz, Germany
- 4. Shigeto Ikeda, M.D. First flexible fiberoptic bronchoscopy Japan, 1966
- 5. • Definitive history or anticipated difficult intubation • Known or suspected cervical spinal injury or disease • ? failed intubation
- 6. Fiberoptic intubation modes Anesthetized oral Anesthetized nasal Awake oral Awake nasal
- 7. 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
- 8. : م1 2051 م 8 ASA monitors to be applied
- 9. : م1 2051 م 9 Sedation Fentanyl and midazolam most widely used. Dexmeditomidine, alfentanyl, remifentanyl and propofol are suitable alternatives My dear: Anesthesiologist is sick today
- 10. : م1 2051 م 10 Take home message#1 The goal is to provide conscious sedation to afford comfort and amnesia
- 11. : م1 2051 م 11 Be ready for GA Be ready for emergency airway Be ready for systemic toxicity of local anesthesia
- 12. : م1 2051 م 12 Anesthesia of oral cavity & pharynx- Non invasive: Topicalization Invasive: 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
- 13. : م1 2051 م 13 A: Topicalization Lidocaine nebulization and atomization Cotton-tipped swabs soaked in lidocaine left for several minutes in mouth or nose Spraying through the work channel of the scope Also we can use: Lidocaine 5% ointment Lidocaine lollipop Lidocaine 4% gargle EMLA 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 wall Protrude tongue; sprayed lateral & posterior laryngopharyngeal wall Approximate; 4-5 metered sprays
- 14. : م1 2051 م 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.
- 15. Anesthesia for the nares. • Progressively larger sized soft nasal airways coated with 2% lidocaine.
- 16. 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
- 17. Tracheal anatomy depicting Superior Laryngeal Nerve with the internal and external branch.
- 18. 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.
- 19. • 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.
- 20. 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.
- 21. 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
- 22. • 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.
- 23. : م1 2051 م 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
- 24. : م1 2051 م 24 Take home message #2 Sedation will not compensate for poor topicalization
- 25. 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 .
- 26. 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.
- 27. 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.
- 28. 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.
- 29. Disadvantages • Not a useful guide for the fiberscope. • Chances of tube dislodgement while removing bite block.
- 30. Williams airway • Longer piece serves as a better guide to the fiberscope. But increases likelihood of tube dislodgement. • Not comfortable to an awake patient.
- 31. Ovassapian airway Same length & curvature as williams airway and : similar problems Advantage: Dorsal openings allowing it to be removed without sliding over the tube.
- 32. Patil mask • Adapter through which the fiberoptic is introduced. • Mask permits non invasive ventilation of the patient during the intubation process.
- 33. : م1 2051 م 33 Push the tongue caudally with tongue depressor on middle of tongue: it will pop out. Tongue pulling out Open up the airway
- 34. : م1 2051 م 34 Hold the tongue with a gauze and pull it out Tongue pulling out
- 35. : م1 2051 م 35 Pulling out tongue will elevate the epiglottis away from the posterior pharyngeal wall Take home message #3
- 36. : م1 2051 م 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 transmission 7)Light source: Can be a portable battery powered source or via a cable 8)Suction valve and port Anatomy of the bronchoscope
- 37. : م1 2051 م 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
- 38. : م1 2051 م 38 Flexion lever moves tip of the scope from 06:00 to 12:00 in one plane
- 39. : م1 2051 م 39 To flex the tip in other planes, rotate the entire scope
- 40. Fiberscope with endotracheal tube mounted .
- 41. Fiberscope with laryngeal mask airway mounted.
- 42. : م1 2051 م 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).
- 43. : م1 2051 م 43 Marker to be put at 12;00 to maintain spatial orientation
- 44. : م1 2051 م 44 Line up the fiberoptic shaft . Know where that tip points before it disappears from view!
- 45. : م1 2051 م 45 As in laparoscopic surgery either at right or left of the patient depending on the dominant hand Position of the anesthesiologist
- 46. : م1 2051 م 46 Position of the anesthesiologist
- 47. : م1 2051 م 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.
- 48. (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 48 Handling of the fiberopticbronchoscope.
- 49. 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.
- 50. : م1 2051 م 50 Defog the tip by Defogger Warm water Against buccal mucosa
- 51. : م1 2051 م 51 Pink color is seen if you position the scope against tongue suface Now you are ready to go
- 52. : م1 2051 م 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 .
- 53. : م1 2051 م 53 Keep the tongue in the botom half of the view by rotating the hand holding the tip of the scope
- 54. : م1 2051 م 54 Keep lumen of the airway centered Keep tongue in view
- 55. : م1 2051 م 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
- 56. : م1 2051 م 56 use the lever to flex or extend the distal end of the scope Advance the scope into the trachea
- 57. : م1 2051 م 57 Determine the right and left main brochi Do not touch the carina
- 58. • 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.
- 59. • 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.
- 60. Happy sight
- 61. Sad sight.
- 62. 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
- 63. : م1 2051 م 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
- 64. : م1 2051 م