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A 65-year-old male with carcinoma of the colon presents for colon resection. He weighs 120 kg and is 157 cm tall (BMI 48 kg·m−2). He has a history of hypertension and obstructive sleep apnea. On airway examination, he has a Mallampati IV score; 3-cm mouth opening, a large tongue, full dentition, about 0.5 cm of mandibular protrusion, a receding mandible, decreased cervical spine extension, and has a short thick neck. His cricothyroid membrane is difficult to palpate. He has predictors of difficult direct laryngoscopy, difficult video-laryngoscopy, difficult bag-mask-ventilation, difficult extraglottic device (EGD) use, and a difficult surgical airway. He is likely to be intolerant of apnea. An awake bronchoscopic intubation was performed which was uneventful as was his subsequent surgery.


How Did Bronchoscopic Intubation Develop?

Transmission of a visual image through a flexible fiberoptic bundle was first reported by Hopkins and Kapany in 19541 and the first recorded endoscopic tracheal intubation was reported by Murphy in 1967.2 In that case report, the trachea of a patient with Still's disease was successfully intubated through the nose using a flexible choledochoscope.2 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.3,4 A series of 100 tracheal intubations using the flexible bronchoscope was reported in 1972, with a success rate of 96%.5 However, utilization of flexible fiberoptic technology for endotracheal intubation remained limited among health care providers throughout the 1970s and 1980s.6 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.6 Following the publication of the ASA Guidelines on Difficult Airway Management in 1993,7 the use of flexible bronchoscopic intubation (FBI) among anesthesia practitioners greatly increased8 and the technique has come to play a pivotal role in the management of the difficult airway.9-11

Although it has been advocated as the technique of choice in the management of the difficult intubation,12-15 this view is not universally shared and a reluctance to perform awake bronchoscopic intubation continues to occur.16,17 In 2011, the 4th National Audit Project of the Royal College of Anesthetists and the Difficult Airway Society (DAS)10 reported a failure to consider or employ awake bronchoscopic intubation as a first choice in difficult airway management when it was clinically indicated and that harm occurred as a result. However, surveys from the United States, France, and Denmark published between 1998 and 2003 confirm the widespread use of flexible bronchoscopes particularly for management of the anticipated difficult airway.18-22 A Canadian survey published in 2005 (2066 surveys sent, 47% response rate) ...

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