CORRESPONDENCE |
Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: more solutions
* E-mail: airwayman{at}doctors.org.ukEditor—We read with interest the excellent review article on the difficulty in advancing a tracheal tube over a fibreoptic bronchoscope1 and we applaud the authors for their useful discussion and suggested solutions, but we would like to highlight certain points.
We agree with the authors that view of the larynx and passing a tube over a fibrescope can be made easier by direct laryngoscopy. In the case of using the jaw thrust manoeuvre to clear the airway, the authors suggested releasing the jaw thrust when a tube is passed over a fibrescope as maintaining jaw thrust can lead to widening of the oesophageal inlet and hence more chance of oesophageal placement. In our opinion, when such difficulty is encountered it is likely to be associated with relative inexperience on the part of the assistant in fibreoptic intubation skills. The aim of thrusting the jaw is to increase the air space in the oropharynx, thus allowing location of the glottis. If jaw thrust is not maintained correctly (only partially maintained), then it is more likely that the soft palate, tongue and epiglottis approximate to the posterior pharyngeal wall, so increasing the possibility of tube displacement. We strongly recommend maintaining jaw thrust until the tube is successfully passed into the trachea.
Finally, difficulty can also be encountered even in experienced hands in the absence of an ergonomic environment and when the position of the investigator relative to the patient and the camera is different from the routine setting. Attention to such simple details can increase the success rate of both fibreoptic intubation and the passage of tube into the trachea.
Cardiff, UK
References
1 Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions. Br J Anaesth 2004; 92: 870–81
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