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A 78-year-old male presents for surgical fixation of an unstable cervical spine fracture. He weighs 50 kg and is 157 cm tall (BMI 20.3 kg·m−2). He has a history of ankylosing spondylitis and hypertension. On airway examination, his neck is immobilized in a hard cervical collar, but it is apparent that he has a significant fixed neck flexion; Mallampati III score; 2 cm mouth opening, full dentition and a receding mandible. He has predictors of difficult face-mask ventilation, difficult direct laryngoscopy, difficult video laryngoscopy, and difficult EGD use. Due to the presence of an unstable cervical spine injury and multiple predictors of a difficult airway, an awake bronchoscopic intubation was performed which was uneventful as was his subsequent surgery.


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 bronchoscope using fiberoptic technology was first 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 Following the publication of the ASA Guidelines on Difficult Airway Management in 1993,6 the use of flexible bronchoscopic intubation (FBI) among anesthesia practitioners greatly increased7 and the technique has come to play a pivotal role in the management of patients with a difficult airway.8 In a review of general anesthetics administered at a Canadian tertiary care center between 2002 and 2013, 1554 of the 146,252 (1.06%) intubations were performed awake and a flexible bronchoscope was used in 99.2% of these awake intubations.9

Surveys from the United States, France, and Denmark published between 1998 and 2003 confirm the widespread use of flexible bronchoscopes particularly for the management of the anticipated difficult airway.10–14 A Canadian survey in 2013 revealed that 98% of respondents had performed awake FBI and 93% were comfortable with the technique. In addition, 91% had performed asleep FBI and 88% were comfortable with the technique. When presented with an unanticipated difficult intubation with failed direct laryngoscopy, 41% chose FBI as the first-choice alternative, whereas 90% chose a video laryngoscope.15 Although it has been advocated as the technique of choice in the management of difficult intubation,16–19 this view is not universally shared and a reluctance to perform awake bronchoscopic intubation continues to occur.20,21 An American study reported a decreasing use of bronchoscopic intubation over 12 years ending in February 2013.22 In ...

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