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  • Print publication year: 2010
  • Online publication date: January 2011

Chapter 13 - Tracheal intubation: flexible fibreoptic

from Section 2 - Clinical


One of the ways of producing some structure to the way in which we think about managing normal and difficult airways is by algorithm or flow-chart. Sedation makes treatments such as endoscopies, tracheal intubation, dental treatment and minor surgical procedures more tolerable. Neuro-muscular blocking drugs (NMBS) are powerful drugs, indubitably dangerous in untrained hands. NMBDs make a vital contribution to patient safety; it is worth recalling what anaesthetic practice must have been like without them. The classic causes of acute airway obstruction include haematomas or tissue swelling after thyroid or anterior cervical spine or carotid surgery, trauma, or pharyngeal and laryngeal infections. Humans make errors, which in retrospect can seem distressingly obvious. Those involved in airway management need to appreciate that in critical situations there will not be time for detailed, analytical decision making, and be wary of fixating on issues or techniques that are not contributing to success.

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Further reading

AsaiT, ShinguK. (2004). Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope. Incidence, causes and solutions. British Journal of Anaesthesia, 92, 870–881.
AshchiM, WiedemannHP, JamesKB. (1995). Cardiac complication from use of cocaine and phenylephrine in nasal septoplasty. Archives of Otolaryngology-Head Neck Surgery, 121, 681–684.
British Thoracic Society. (2001). Guidelines on diagnostic flexible bronchoscopy. Thorax, 56, i1–i21.
CaraDM, NorrisAM, NealeLJ. (2001). Pain during awake nasal intubation after topical cocaine or phenylephrine/lidocaine spray. Anaesthesia, 87, 549–558.
CookTM, AsifM, SimR, WaldronJ. (2005). Use of a Proseal laryngeal mask airway and a Ravussin cricothyroidotomy needle in the management of laryngeal and subglottic stenosis causing upper airway obstruction. British Journal of Anaesthesia, 95, 554–557.
HendersonJJ, PopatMT, LattoIP, PearceAC. (2004). Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia, 59, 675–694.
JonesHE, PearceAC, MooreP. (1993) Fibreoptic intubation. Influence of tracheal tube design. Anaesthesia, 48, 672–674.
KnolleE, OehmkeMJ, GustorffB, HellwagnerK, KressHG. (2003). Target-controlled infusion of propofol for fibreoptic intubation. European Journal of Anaesthesiology, 20, 565–569.
MakaryusJN, MakaryusAN, JohnsonM. (2006). Acute myocardial infarction following the use of intranasal anaesthetic cocaine. Southern Medical Journal, 99, 759–761.
MaktabiMA, HoffmanH, FunkG, FromRF. (2002). Laryngeal trauma during awake fiberoptic intubation. Anesthesia and Analgesia, 95, 1112–1114.
MarfinAG, IqbalR, MihmF, PopatMT, ScottSH, PanditJJ. (2006). Determination of the site of tracheal tube impingement during nasotracheal fibreoptic intubation. Anaesthesia, 61, 646–650.
OvassapianA. (1996). Fibreoptic Endoscopy and the Difficult Airway. 2nd Ed. Philadelphia: Lippincott-Raven.
PopatM. (Ed.). (2009). Difficult Airway Management. Oxford: Oxford University Press.
PopatM. (2001). Practical Fibreoptic Intubation. Oxford: Butterworth-Heinemann.
RaiMR, ParryTM, DombrovskisA, WarnerOJ. (2008). Remifentanil target-controlled infusion vs. propofol target-controlled infusion for conscious sedation for awake fibreoptic intubation: Double-blinded randomized controlled trial. British Journal of Anaesthesia, 100, 125–130.
SilkJM, HillHM, CalderI. (1991). Difficult intubation and the laryngeal mask. European Journal of Anaesthesiology, 4, 47–51.
WylieS, CalderI. (2008). Flexible fibreoptic intubation. Anaesthesia and Intensive Care Medicine, 9, 358–362.

Websites of interest

Oxford Region Airway Group (ORAG)
Difficult Airway Society (DAS). UK.