Improved technique for fiberoptic intubation

Bronchoscopy in the intensive care unit

The development of the flexible, fiberoptic bronchoscope has made bronchoscopic examinations possible in ICU patients undergoing mechanical ventilation. Over the years, the number of such procedures has greatly increased, with both diagnostic and therapeutic objectives, such as performing difficult intubation, management of atelectasis and hemoptysis, diagnosis of nosocomial pneumonia in ventilated patients, and early detection of airway lesions in selected situations, such as high-frequency ventilation. The complication rate can be kept low if the endoscopist has a precise knowledge of the many pathophysiological and technical facets particular to bronchoscopy under these difficult conditions. This article reviews some of these aspects, in the light of our personal experience.

End-tidal carbon dioxide monitoring during awake blind nasotracheal intubation

STUDY OBJECTIVE

To test the usefulness of the end-tidal carbon dioxide monitor in facilitating awake blind nasotracheal intubation in patients with potentially difficult airways.

DESIGN

Randomized, controlled comparison of regimen.

SETTING

Inpatient surgery clinic at a university hospital.

PATIENTS

Sixty-one consecutive patients with potentially difficult airways.

INTERVENTIONS

After airway anesthesia with 4% lidocaine was administered to all patients, either fentanyl and diazepam (n = 30) or fentanyl alone (n = 31) was given intravenously before the awake blind nasotracheal intubation procedure.

MEASUREMENTS AND MAIN RESULTS

End-tidal carbon dioxide concentration, arterial blood pressure, heart rate, and arterial oxygen saturation (by pulse oximeter) were measured in each patient during the awake blind nasotracheal intubation procedure. The day after anesthesia and surgery, each patient was asked to assess the degree of discomfort experienced during the procedure. In 54 of 61 patients, the end-tidal carbon dioxide monitor facilitated awake blind nasotracheal intubation. End-tidal carbon dioxide was significantly higher in patients given both fentanyl and diazepam than in those given fentanyl alone (7.4% +/- 1.4% vs 5.9% +/- 0.9%, respectively; p less than 0.05), but no patient in either group recalled the awake intubation as extremely uncomfortable.

CONCLUSIONS

Monitoring of end-tidal carbon dioxide is useful and valuable in both facilitating blind nasotracheal intubation and avoiding profound hypoventilation.

Clinical competence in the performance of fiberoptic laryngoscopy and endotracheal intubation: a study of resident instruction

Anesthesiologists must be competent in the technique of fiberoptic laryngoscopy and intubation in airway management. The goal of this study was to test the hypothesis that an acceptable level of technical expertise in fiberoptic laryngoscopy and intubation may be acquired within 10 intubations while maintaining patient safety. The learning objectives were an intubation time of 2 minutes or less and greater than 90% success on the first intubation attempt. Ninety-one ASA physical status I-II patients with normal laryngeal anatomy had general anesthesia and were intubated orally with an Olympus LF-1 fiberoptic scope; the mean (+/- SD) time for intubation was 1.92 +/- 1.45 minutes. Four residents with no prior experience with fiberoptic laryngoscopy intubated at least 15 patients each. A learning curve was generated using logarithmic analysis of the mean (+/- SD) time for intubation of patients 1 to 15 for all residents combined. The curve showed that the mean (+/- SD) intubation time decreased from 4.00 +/- 2.91 to 1.53 +/- 0.76 minutes within the first 10 intubations. After the tenth intubation, the mean time was 1.53 minutes and the percent success on the first attempt at intubation was greater than 95%. There were no clinically important changes in O2 saturation, mean arterial pressure (MAP), or heart rate (HR) as a consequence of fiberoptic intubation. The results suggest that an acceptable level of technical expertise in fiberoptic intubation can be obtained (as defined by the learning objectives) by the tenth intubation, and patient safety is maintained.(ABSTRACT TRUNCATED AT 250 WORDS)