The Flexible Rhino-Laryngoscope for Awake Nasotracheal Intubation
August 2nd, 2024
Presented here is a protocol for awake nasotracheal intubation using a flexible rhino-laryngoscope with a 300 mm working length. As this tool is minimally invasive and easy to manipulate, awake intubation performed with a flexible rhino-laryngoscope is well-tolerated, fast, and safe for patients with difficult airways.
This survey aims to provide a comprehensive description of the awake nasal tracheal intubation technique using a flexible rhino-laryngoscope. We propose that this method could serve as a safe, simple, and economical alternative to the conventional fiber optic bronchoscope. Despite its recognized benefits, awake intubation remains underused in clinical practice.
This research aims to investigate whether the shorter flexible scope can make the procedure more accessible and practical, encouraging its broader adoption. A shorter scope can improve maneuverability and decrease the likelihood of buckling. It can be operated with one hand, freeing the other to adjust the patient's head.
It aids in the proper alignment of the scope with the glottis, allowing for the operator to focus on the anatomical landmarks when navigating towards the trachea. The flexible rhino-laryngoscope could be a significant asset to the airway management toolkit for anesthesia providers, offering benefits for the assessment and management of patients with difficult airways. To begin, position the patient on the operating table in a sitting or semi-recumbent position.
Perform the American Society of Anesthesiologists defined monitoring procedure. Evaluate the airway using a 300 to 350 millimeter working length flexible video rhino-laryngoscope with the most suitable nostril for ETT placement. Check for septal deviation, bony spurs, and turbinate hypertrophy.
Inspect the pharynx and the paraglottic space, vocal cords, and subglottic region to the mid trachea. Using the working channel of the scope or a curved oropharyngeal catheter under fiber optic guidance, administer lidocaine topically dripping over the glottis and the vocal cords. Start the maneuver with the flexible rhino-laryngoscope armed with an intubating tube.
Use 2%lidocaine gel to lubricate a reinforced, cuffed ETT with an internal diameter of 5.5 to 6.5 millimeters. Place the fibroscope inside the ETT, ensuring that the proximal end of the tube covers the transitional part of the fibroscope handle. Introduce the fibroscope ETT ensemble in the selected nostril.
Orient the bevel of the ETT laterally during the nasal passage. Then slowly advance following the nasal floor and the septum. Rotate the tube with small movements if an obstacle is encountered during the nasal passage.
When the scope reaches the pharynx, stop the advancement and search for epiglottis, arytenoids, or vocal cords. Advance the tube to the mid tracheal level. After confirming proper tube placement with the tip two to four centimeters above the carina, with fiber optic visualization, remove the fiber scope, then connect the patient to the ventilator to ensure proper capnography waveform and spontaneous movement of the ventilation bag.
Secure the ETT in position with tape and use a flexible extension corrugated tube to connect the ETT to the breathing circuit. The average duration from the insertion of the intubating tube through one nostril to the confirmation of endotracheal intubation was around 76 seconds.
Overview
This article presents a protocol for awake nasotracheal intubation using a flexible rhino-laryngoscope. This method is minimally invasive, well-tolerated, and safe for patients with difficult airways.
Key Study Components
Area of Science
- Anesthesia
- Airway management
- Clinical protocols
Background
- Awake intubation is often underused despite its benefits.
- Flexible rhino-laryngoscopes can improve maneuverability.
- This technique may serve as an alternative to conventional methods.
- Shorter scopes decrease the likelihood of buckling.
Purpose of Study
- To investigate the feasibility of awake nasal tracheal intubation.
- To promote broader adoption of this technique in clinical practice.
- To assess the advantages of using a flexible rhino-laryngoscope.
Methods Used
- Protocol development for awake intubation.
- Comparison with conventional fiber optic bronchoscopy.
- Evaluation of the flexible rhino-laryngoscope's performance.
- Patient tolerance and safety assessments.
Main Results
- Awake intubation with the flexible scope is fast and safe.
- Patients tolerate the procedure well.
- Improved maneuverability enhances the procedure's effectiveness.
- Potential for increased clinical adoption of the technique.
Conclusions
- The flexible rhino-laryngoscope is a viable alternative for intubation.
- Awake intubation can be performed safely and efficiently.
- Further research may encourage its use in difficult airway management.
Frequently Asked Questions
Executive Industry Relevance
Securing the airway in patients with anatomical challenges remains a critical inflection point in perioperative and emergency care, with direct implications for patient safety and procedural success. The flexible rhino-laryngoscope for awake nasotracheal intubation offers a minimally invasive, rapid, and maneuverable solution, reducing the risk of airway management failure. Its adoption can enhance predictive confidence and operational readiness in high-risk airway scenarios across clinical research and device development pipelines.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables functional assessment of airway management tools in anatomically complex models.
- Supports mechanistic de-risking by allowing real-time visualization and navigation of airway structures.
- Facilitates hypothesis testing for device performance and safety in preclinical validation.
Screening & Assay Development
- Provides a standardized protocol for evaluating airway device maneuverability and placement accuracy.
- Delivers reproducible, quantitative metrics such as intubation time and anatomical alignment.
- Enables rapid screening of device modifications or adjuncts for airway access.
Translational & Preclinical Research
- Aligns with disease-relevant models of airway obstruction for translational continuity.
- Supports risk-adjusted advancement of airway management technologies into clinical feasibility studies.
- Offers predictive value for patient tolerance and procedural safety in diverse populations.
Pipeline & Workflow Integration
This flexible scope protocol integrates into the device evaluation continuum from early discovery through preclinical and translational research, supporting iterative optimization and readiness for clinical adoption.
- Discovery Biology: Enables direct visualization and manipulation of airway anatomy for hypothesis-driven device testing.
- Screening: Standardizes assessment of device performance metrics, including intubation speed and anatomical navigation.
- Analytics: Provides quantitative outputs such as procedure duration and placement confirmation for comparative analysis.
- Translational Research: Bridges preclinical findings with clinical feasibility in patients with difficult airways.
- Enterprise Reuse: Establishes a reusable protocol for evaluating airway devices across multiple research and development programs.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence in airway device performance and patient safety.
- Operational Value: Enhances standardization, reproducibility, and procedural efficiency in airway management studies.
- Strategic Value: Informs go/no-go decisions for device advancement and reduces late-stage risk in airway management portfolios.
- Portfolio Impact: Supports risk-adjusted prioritization of airway technologies for clinical translation.
Implementation Considerations
- Requires expertise in airway anatomy and flexible endoscopic manipulation.
- Needs access to flexible rhino-laryngoscopes and compatible endotracheal tubes.
- Demands cross-team standardization of procedural steps and outcome metrics.
- May require adaptation for use in various preclinical or clinical model systems.
- Potential limitations include anatomical variability and operator learning curve.
