Dr Ravi Mundada

Consultant Anaesthesiologist
Suretech Hospital, Nagpur

In cases of anticipated difficult intubation, my preference is for awake fibre optic intubation, employing a slightly different approach that simplifies the procedure, enhances safety, ease, and speed. In the conventional method, the endotracheal tube (ETT) is threaded over the bronchoscope, followed by bronchoscopy, and the entire length of the ETT is slid downwards. However, this approach can lead to challenges, such as getting lost in the nasal cavity or encountering significant resistance, causing discomfort for the patient.

After encountering these challenges in conventional bronchoscopy, I developed a modified approach. I decided to first insert a flexometallic ETT from the nose to the nasopharynx and then introduce the bronchoscope through it. This modification has proven to make the procedure more straightforward, faster, and more comfortable for the patient.

Here is a breakdown of my method:

  1. Preoperative visit to explain the procedure to the patient, obtaining their cooperation during the intervention.
  2. Nebulization with 4% xylocaine.
  3. Administration of adequate topical anesthesia with lignocaine jelly after ensuring proper patency of the nares.
  4. Insertion of an appropriately sized flexometallic ETT from the nares to the nasopharynx.
  5. Light sedation with midazolam and fentanyl (optional).
  6. Introduction of the bronchoscope through the ETT until the vocal cords are visible.
  7. Spraying 2% lignocaine (2+2cc) over the vocal cords, waiting for 20 to 30 seconds, and then advancing the scope until just about the carina.
  8. Sliding the remaining ETT and adjusting it above the carina.

Advantages of this method include:

  1. The Flexometallic ETT acts as a tunnel for the scope from the nares to the nasopharynx, bypassing nasal cavity resistance.
  2. It becomes easier to pass the scope to the supraglottic area, and the remaining ETT can be inserted more smoothly.
  3. The actual procedure requires less time.
  4. Anesthesiologists with limited knowledge of the nasal cavity and nasopharynx can perform the procedure more easily.

This simple modification of placing the ETT before bronchoscopy enhances the ease, safety, and speed of the procedure, making it more patient-friendly. To truly appreciate the simplicity of this method, one must experience it firsthand.