Flexible fibreoptic laryngoscope - PowerPoint Presentation

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Flexible fibreoptic laryngoscope

Dr. S.

Parthasarathy

MD., DA., DNB,

Dip.

Diab

., DCA,

Dip. Software statistics-

PhD ( physiology) , IDRA, FICA

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History

Dr

P.

Murphy who, in 1967,stills disease reported using the newly invented choledochoscope - intubation of the tracheaDavies 1973 – check position Raj 1974 = DLT Critically ill Difficult airways

Nomenclature varies

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Advantages

Maneuverability

SAD

Oral and nasal In vision intubation Awake also for biopsies , ICU , placement of blockers DLT etc

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Disadvantages

Cost

Technique learning

Size of the tube – depends on scope Blood and secretions Can we deliver oxygen effectively ? Sterilization ? Cork in bottle effect in obstructed patients

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Indications

Anticipated difficult tracheal

intubation

   or mask ventilation,    Confirmation of tracheal tube position  , DLT, BB , , post op VC  Diagnosis of malfunction of a supraglottic airway device   

Cervical spine instability

Assessment

of swelling or trauma after difficulty with airway management

Tracheal tube change (between the nasal and oral routes)    Intensive care use, including aspiration of secretions and confirmation of the dilatational tracheotomy site

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Contra indications

Lack of airway skills

Difficult airway with impending airway obstruction

Allergy to local anaesthetic agents (rare)Infection/ contamination of the upper airway – blood, friable tumour, open abscessGrossly distorted anatomyFracture base of skull (C/I to nasal route)Penetrating eye injuriesPatient refusal or uncooperative patient.

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Airway obstruction ? Contraindicated ?

1. sometimes the aperture is so small that the entry of FOL will compromise on whatever the entry of gases !!

2. But we can use FOL to introduce a guidewire through which bougie with oxygen can be given later intubated

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How does it look like ?

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Pictures taken from internet and other sources for closed academic purpose only

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Parts

Light source

Handle

Insertion portion

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Light source

The light source is contained in a separate box, uses mains power, and is connected to the scope by a universal (light transmission) cord. A bright light without much heat is produced..

A handle with batteries that uses a halogen light bulb is compact, convenient, and inexpensive- but weak light

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light conducting Bundle

Incoherent bundle

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Handle

Eye piece

Focus ring Lever Light source Working channel

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Control lever

The tip (bending,

angulation

) control lever or knob may be on the side of the body or a thumb-controlled lever system on the back of the handle. By turning this lever, the insertion cord tip can be flexed or extended in one plane. A full range of motion can be achieved by rotating the entire instrument. Many fiberscopes have a tip-locking lever that locks the tip in a desired position

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Working

Light

Eye piece

Lever

Focussing

ring

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Working channel

The suction or working channel extends from the handle of the FOB to the tip of the insertion cord

suction secretions,

spray local anesthetics, pass various biopsy and brush instruments, insufflate oxygen.

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Insertion cord

Two tip flexion cables (

angulation

wires, control wires, tip-bending control wires) connecting the tip to the bending knob on the handle are placed along the sides of the insertion cord.Braiding is different in the tip !

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Pictures taken from internet and other sources for closed academic purpose only

Image

fibres

Light source(2) Working channelAngulation

wires(2)

Wrapper

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Construction

Insertion cord diameter ranges from 2.2 to 5.7 mm

Length is from 600 to 650 mm

Working channel none to 2.2 mm Tip bending – up 120 - 180 , down 120 – 140 Viewing tip – 75 degrees to 120 degrees The connection of the handle to the insertion portion is usually tapered to hold the tracheal tube.

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Washing

The FOB should be washed immediately after each use, and the working channel should be flushed with water to remove secretions before they dry. The use of a cleaning brush may be needed for complete removal of secretions from the working channel.

Some manufacturers even produce fully

autoclaveable flexible fibrescopes..

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Sterilisation

Retrograde insertion of a wire through the working channel -- NO

Fully immersible in

glutaraldehyde Soak in soap solution five minutes followed by dry cleaning and glutaraldehyde for 5, 10 or 15 minutes then dry

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Technique – tips

No movement with the tip flexed

Unconscious patient , the epiglottis and tongue may fall –

Test the light Antifog with warm water and not normal saline Show to buccal mucosa

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Technique – tips Focus at 2 cm approx

Cord lubricated - see the tip full of gel means vision impaired

Check control lever

Oxygen Well gelled tube advanced and fit with proximal end of the cord

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Tips !

Don’t use the tip for dissecting tissues

If tongue falls , ask the person to stretch out or a simple gauze piece stretch by the attendee nearby ( awake or

anesthetised) A lot of special airways !!

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Williams

Berman

Ovassipian

Patil

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Oral

(maneuverable path)

or

nasal ( fixed path )

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Increase success !!

Larger scope

Flexometallic

tube Well gelled tube airway exchange catheter Warming the tube Bevel down tube

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Preparation of the Patient

Psychological

Inform

Reassure Active participation Pharmacological Glyco sedation Fentanyl Airway anesthesia

Seven liters per

minute oxygen through working channel has

been ideal for directing secretions away,

helping defog

the lens, and oxygenating the patient.

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Stand straight above in a stool FOL is straight

See the tip

Tunnel between palate and

nasopharynx See the shaft direct may be up to 10 cm

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FFOL introduced into the nares

See the

turbinates Nasopharynx

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Centre the scope

Go further down to see the epiglottis (1)

Then the glottis (2)–

upto 3 cm above carina(3)Pull the tongue/ jaw thrust

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Large floppy epiglottis

Difficult to negotiate

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90 degrees rotation

No hang ups

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Where do we want to look ?

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The anesthetist moving

from side to side, lifting and twisting

their shoulders

as they manipulate the scope. This body movement does nothing to improve control of the scope; in fact, it destroys the laryngoscopist’s optimal alignment with the patient.No further movement of the scope on resistance !

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Can get the scope to the umbilicus to get the natural curve

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Technique – tube insertion

To thread the well gelled tube

Gets stuck in the vocal cords

Change direction of the bevel / decrease or increase the flexion of the neck To ensure adequate nasopharyngeal patency and to reduce nasal trauma, sequential introduction of increasing sizes of small flexible nasopharyngeal airways can be used to dilate the nasal passages gently. This maneuver ensures that the ET easily threads over the FOB and into the trachea

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Nasotracheal intubation is easier with

fibre

optic because of the alignment of the passage with the glottis –--

Put the tube first or put the FOB first

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Tube first – nasal bleeding Cant maneuver the FOB

But after achieving the larynx, tube can be threaded

Good suction before FOB

If we put the FOB first , sometimes a threaded tube may not cross the nasal cavity Tube oval – no FOL

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A good view may be spoilt by

blood = red out,

secretions = white out,

no cavity = pink out, Area is not anesthetised – withdraw 2 cm spray as you go and advance FOL in the centre always

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Tips

Keep the air cavity (the dark space) constantly in the centre of your visual field. The awake patient can assist in opening the airway by protruding the tongue (opens

oropharynx

), saying “eeh” (opens pharynx, and epiglottis comes into view), deep inspiration (opens glottis)Light can illuminate upto 4 cm only

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Fiberoptic-Assisted Retrograde Guidewire

Intubation

FOB is inserted into the ET and is advanced alongside the

guidewire past the end of the ET and beyond the entrance of the guidewire into the trachea. When the position of the FOB is assured in the lower trachea, the guidewire is removed and the ET is threaded over the FOB into the tracheathread the guide wire through the suction channel and proceed with the FOB

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Other avenues

Fibre

optic laryngoscope through LMA and intubation

FFOL and intubation through combitube FFOL through the other nares and pass the tube blind nasal through the other nares and redirect the tube with change in positions

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Complications

Local anesthetic drug toxicity

Failure to

intubate the tracheaphysiological effects of awake intubations include moderate hypoxia (mean 6 mmHg) and mild hypercarbia (mean 7.5mmHg) with a mean of 5.4% drop in oxygen saturationLaryngeal trauma

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Summary

FFOL ?!

Parts

Indications advantages Disadvantages Technique Tips Other methods Complications