The Flexible Rhino-Laryngoscope for Awake Nasotracheal Intubation

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.