THE FLEXIBLE BRONCHOSCOPE: A Tool for Anesthesiologists

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Soon after the introduction of the flexible bronchoscope into clinical medicine, anesthesiologists recognized its value in airway management.4, 14, 37, 38, 49, 71 Because of its continuous refinement, the introduction of new techniques in fiberoptic airway management, and the relative ease of exploring an airway with it, the scope of the anesthesiologist's role in airway management has been expanded.2, 16, 29, 32, 59, 72 The enormous popularity of the flexible bronchoscope in anesthesia practice has led to the publication of books and monograms devoted to its role in that setting.43, 44, 53, 57 The flexible bronchoscope is used for airway management more than any other intubation technique or device, even though it was not developed for this purpose nor used for the first fiberoptic tracheal intubation. A flexible fiberoptic choledochoscope was used to perform the first fiberoptic nasotracheal intubation in a patient with a difficult airway complicated by Still's disease.38 Today, the flexible bronchoscope is used for many perioperative applications including tracheal intubation, endobronchial placement of double-lumen tubes and blockers, and evaluation of the airway:

  • A

    Diagnostic

  • B

    Therapeutic

  • C

    Problem solving

    • 1

      Management of failed intubation

    • 2

      Management of difficult intubation

    • 3

      Management of failed positioning of endobronchial tubes and blockers

    • 4

      Identification of the causes of acute hypoxemia

  • D

    Other

    • 1

      Fiberoptic changing of the endotracheal tube

    • 2

      Checking nasogastric tube position

    • 3

      Checking jet stylet position

    • 4

      Evaluation for optimal time of extubation

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]

    *

    Airway Study and Training Center, Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois

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