Chapter 9

### 9.1.1 How Did Bronchoscopic Intubation Develop?

The first recorded endoscopic tracheal intubation was reported by Murphy in 1967.1 In that case report, the trachea of a patient with Still's disease was successfully intubated through the nose using a flexible choledochoscope.1 The flexible fiberoptic bronchoscope was introduced into clinical practice in 1964, and although it was not developed for the purpose of airway management, its value as a device to facilitate endotracheal intubation was soon appreciated.2,3 A series of 100 tracheal intubations using the flexible bronchoscope was reported in 1972, with a success rate of 96%.4 However, utilization of flexible fiberoptic technology for endotracheal intubation remained limited among health-care providers throughout the 1970s and 1980s.5 Seventy-five percent of those who completed questionnaires at a series of fiberoptic bronchoscope workshops between 1984 and 1989 had either no or minimal experience with the technique.5 Following the publication of the ASA Guidelines on Difficult Airway Management in 1993,6 the use of flexible bronchoscopic intubation among anesthesia practitioners greatly increased7 and the technique has come to play a pivotal role in the management of the difficult airway.8

Although it has been advocated as the technique of choice in the management of the difficult intubation,9-12 this view is not universally shared and a reluctance to perform awake bronchoscopic intubation continues to occur.13,14 However, surveys from the United States, France, and Denmark published between 1998 and 2001 confirm the widespread use of flexible bronchoscopes particularly for management of the anticipated difficult airway.15-18

### 9.1.2 When Is Bronchoscopic Intubation Indicated?

The primary indication for bronchoscopic intubation is in the elective (or at least nonemergency) management of the anticipated difficult airway.

When endotracheal intubation is required and there has been a history of previous difficult intubation, or if difficult direct laryngoscopy is predicted on airway assessment, and in particular, when mask-ventilation is also predicted to be difficult, bronchoscopic intubation can be an invaluable alternative intubation technique. Although bronchoscopic intubation in this setting can be achieved under general anesthesia (GA), awake intubation maintains a wide margin of safety.19-21 In general, if airway compromise or respiratory distress exists, awake intubation similarly maintains a wide margin of safety.19 However, in this circumstance, the urgency with which airway control must be achieved and the extent of the airway compromise may limit the choice of technique, and bronchoscopic intubation may not be feasible or appropriate. In addition, incomplete local anesthesia of the upper airway makes bronchoscopic intubation more difficult, as does the presence of blood and secretions in the airway. Complete airway obstruction has been reported following the topical application of local anesthesia to the airway and suctioning in preparation for awake intubation in a stridorous patient with recurrent neck carcinoma and radiation therapy.22 Complete airway obstruction after application of topical local anesthesia to the upper ...

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