THE FLEXIBLE BRONCHOSCOPE: A Tool for Anesthesiologists
Section snippets
DIAGNOSTIC APPLICATIONS
Bronchoscopy is the examination of the lower airway. With a flexible bronchoscope, however, the upper airway also can be examined30, 31, 35, 54 without distorting its anatomy or physiology. The technique is simple, safe, and well tolerated by an awake patient and causes few hemodynamic changes. When airway evaluation includes the possibility of a tracheal intubation, the fiberscope is mounted with an endotracheal tube before the examination. The trachea then is intubated after the application
THERAPEUTIC APPLICATIONS
The flexible bronchoscope also is used to manage airway problems in the trachea and first-generation bronchial tree. It can help to identify the causes of acute hypoxemia and to remove secretions in the treatment of acute atelectasis.54 Misplaced endotracheal and endobronchial tubes can be identified and repositioned to resolve hypoxemia caused by a nonventilated lobe or segments of the lung.44 The flexible bronchoscope also is indicated for treatment of gastric aspiration8 and traumatic
PROBLEM-SOLVING APPLICATIONS
The most common and appreciated role of the flexible bronchoscope in anesthesia practice is in the management of difficult or failed tracheal intubations. The bronchoscope prevents airway trauma, dental damage, life-threatening complications, case cancellations, or prolonged delays in surgery.7, 44, 78 Patients who otherwise might be denied a general anesthetic or be subjected to tracheostomy, when intubation by rigid laryngoscopy is impossible, may be intubated with the help of the flexible
Endobronchial Intubation for Separation of Lungs
There are medical and surgical indications for separation of lungs to provide one-lung ventilation44:
Surgical
Absolute indications
To prevent contamination of nonoperative lung from secretions and blood
To provide adequate ventilation in the presence of a large bronchopleural fistula
To allow open rupture of giant lung cyst and pneumothorax
Thoracoscopic procedures
Relative indications
To improve surgical exposure for
Pulmonary resections
CAUSES OF FAILURE OF FIBEROPTIC INTUBATION
The success rate in large series of fiberoptic intubations was 98.8%.50 Fiberoptic intubation can fail at any of the three steps of intubation—identification of the larynx, guiding the bronchoscope through the vocal cords, or advancing the ET into the trachea.40 Lack of experience in the use of the bronchoscope contributes to failure of the technique. Other causes of failure include44:
Presence of secretions and blood
Tip of the epiglottis against posterior pharyngeal wall
Large,
ADVANTAGES AND DISADVANTAGES OF FIBEROPTIC INTUBATION
The flexible bronchoscope offers an effective, safe, and easy approach in patients who cannot be intubated with conventional techniques. The cardiovascular response to fiberoptic intubation under general anesthesia is not more favorable than response to rigid laryngoscopy,18, 62, 63, 70 but awake intubation is less stressful and is associated with less severe hypertension and tachycardia.49, 50 Visualization of the airway for evaluation before intubation and tube placement and precise
COMPLICATIONS OF AIRWAY ENDOSCOPY
Complications after fiberoptic airway endoscopy may result from premedication, sedation, local anesthetic drugs, or the procedure itself. Most complications are minor, but life-threatening complications may be encountered.15, 44, 54, 66 The judicious use of appropriate local anesthetic agents minimizes toxic reactions. Laryngospasm, bronchospasm, and coughing are common if topical anesthesia is inadequate. Hemodynamic changes, alone or in combination with hypoxemia, may cause myocardial
SUMMARY
Fiberoptic intubation is the technique of choice in management of a difficult intubation. It should be a first choice, not a last resort after attempts with conventional techniques have failed. It should be mastered by all physicians involved in airway management. The technique is cost-effective because it avoids airway trauma and cancellation of surgical cases because of failed intubation. The flexible bronchoscope for airway management as a diagnostic, therapeutic, and problem-solving tool is
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Address reprint requests to Andranik Ovassapian, MD, Airway Study and Training Center, Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, e-mail: [email protected]
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Airway Study and Training Center, Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois