Orotracheal fibreoptic intubation for rapid sequence induction of anaesthesia*

Abstract

SummaryWe assessed whether¯exible ®breoptic-guided orotracheal intubation could be rapidly and successfully achieved during a simulated rapid sequence induction in 30 anaesthetised and paralysed patients. Rapid sequence induction was simulated by applying practised cricoid pressure. Using a¯exible ®breoptic laryngoscope with camera and closed circuit television, an anaesthetist experienced with the technique performed orotracheal endoscopy and intubation with a cuffed 7.0-mm Portex tracheal tube through a VBM Bronchoscope Airway. Fibreoptic intubation was successful at the ®rst attempt in 28 patients (93%); two patients required two attempts. Mean (SD) time from removal of the facemask from the patient's face to the appearance of carbon dioxide in the expired breath after intubation was 111 (46) s (median 100 s; range 54±195 s). There were one or more dif®culties in 13 patients (43%). These dif®culties were largely avoidable and included problems with ®breoptic equipment, the Bronchoscope Airway, copious secretions, cricoid pressure or railroading of the tracheal tube. Flexible ®breoptic-guided orotracheal intubation may have a place in the management of failed intubation during a rapid sequence induction.

Comparison of times to achieve tracheal intubation with three techniques using the laryngeal or intubating laryngeal mask airway*

“…In another study, we found the mean intubating time for ®breoptic-guided orotracheal intubation during a simulated rapid sequence induction to be 111 s [22]. The mean times we report in all three groups in this study are shorter (Table 2).…”

“…However, if only the laryngeal mask airway was available, then the most suitable tube to use with it is probably the reinforced tracheal tube [21]. Although our study design was developed with the scenario of a failed intubation in mind, and although this scenario often occurs in the context of rapid sequence induction of anaesthesia, we did not apply cricoid pressure during intubation as we have done in a recent study [22]. This is because several studies have shown that use of cricoid pressure impedes both insertion of the laryngeal mask airway and ventilation of the lungs, and it has been suggested that cricoid pressure should be removed, even in the context of failed rapid sequence intubation, to facilitate use of the laryngeal mask airway [23±25].…”

“…This would suggest that, if intubation of the trachea during rapid sequence induction fails, it is quicker to insert a laryngeal mask airway or intubating laryngeal mask airway (thus securing a dedicated airway), and then intubate through it ®breoptically (or blindly in the case of the intubating laryngeal mask airway), than to attempt to intubate the trachea ®breoptically via an oral airway such as the Bronchoscope Airway (Freelance Surgical Promotions, Bristol, UK). Use of the laryngeal mask airway or intubating laryngeal mask airway would have the added advantages of ®rst, maintaining airway patency more effectively than simple oral airways and second, not requiring an extra assistant to maintain jaw thrust as is required during orotracheal ®breoptic intubation [22]. Our study suggests that it is probably more desirable to insert the intubating laryngeal mask airway than the laryngeal mask airway because blind intubation through the former is likely to be very rapid and although it may fail at the ®rst attempt, it is very likely to succeed at the second attempt, and the total time will still be shorter than the alternative methods [7].…”

A comparison of an anterior jaw lift manoeuvre with the Berman airway for assisting fibreoptic orotracheal intubation*

“…1) and Williams airways have been designed to overcome this problem and so facilitate oral fibreoptic endoscopy [4][5][6]. However, these devices may dislodge or obstruct the airway themselves [1,7], and they may not be readily available in all hospitals.…”

Airway research: the current status and future directions

“…Although high-quality investigations are being undertaken [55][56][57][58][59], one problem with our use of devices relates to how we are taught to practise and maintain competencies.…”