FIBEROPTIC NASAL INTUBATION
For the Anticipated Difficult Alrway
INDICATIONS
Elective or nonemergency management of the anticipated difficult airway in the awake, spontaneously breathing patient
Alternative technique when intubation by primary technique is unsuccessful, but face-mask ventilation is successful
Potential cervical instability
Presence of airway trauma
Patient history of radiation for head and neck cancer which may cause airway anatomy distortion
Ludwig's angina
High risk of dental injuries
CONTRAINDICATIONS
Absence of patient cooperation (awake intubation)
Patient refusal
Fixed laryngeal obstruction with stridor at rest; This implies that the airway is less than 4.0 mm in diameter (surgical airway preferred in this setting)
Coagulopathy
Intranasal abnormalities
Basal skull fracture
Paranasal sinusitis
Hypoxia
ADVANTAGES
Permits precise assessment of airway injury
Permits placement of endotracheal tube pass the level of injury
DISADVANTAGES
May not be feasible during situations requiring urgent airway control
Incomplete anesthesia of the upper airway makes this technique more difficult due to the presence secretions and blood
Difficult under general anesthesia
Oxygen desaturation may occur
Lost of submandibular tone - potential airway obstruction
TECHNIQUE
Subtitle
Obtain patient consent
Check equipment and load endotracheal tube onto bronchoscope
Provide oral & nasal topical anesthesia
5 mL of viscous lidocaine via nares; Solution may liquefy and coat the back of the throat
OR
4-10 mL of 4% lidocaine w/ 1 mL of phenylephrine (facemask nebulizer or atomizer)
Identify the more patient nostril
Direct the bronchoscope through the nasal cavity
Direct the bronchoscope through the vocal cords into the trachea
Pass the sleeved endotracheal tube over the bronchoscope
On exiting the distal tube, identifiable structures such as vocal cords will be seen.