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Module 2: Ancillary Equipment - Advanced Knowledge

Bronchoscopic intubation via a supraglottic pathway

This pathway is most often utilized when the patient is anesthetised although it is possible to place a supraglottic airway in an awake patient after topicalization. The supraglottic airway is a conduit for the bronchoscope and ETT and permits ventilation during bronchoscopy.

Video: Bronchoscopic intubation via a supraglottic pathway.


Choice of supraglottic airway


Supraglottic airway Image Advantages & Disadvantages
LMA Classic™

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Advantages:

  • Widely available

Disadvantages:

  • Aperture bars impede passage of the ETT
  • ETT size limitation (size 6 ETT via LMA classic size 3 or 4, size 7 via a size 5.)
  • Length may prevent standard uncut ETT from reaching vocal cords
  • Pilot tube of ETT may not pass through LMA channel
LMA ProSeal™

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Advantages:

  • No aperture bars

Disadvantages:

  • Length may prevent standard uncut ETT from reaching vocal cords
LMA Supreme™

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Disadvantages:

  • Lateral stabilizing bars can obstruct passage of the bronchoscope
  • Length may prevent standard uncut ETT from reaching vocal cords
LMA Excel™

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Advantages:

  • Removable 15mm connector aids in ETT passage
  • Epiglottic elevator bar
  • No aperture bars
Intubating LMA (Fastrach™)

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Advantages:

  • Designed for intubating through
  • Epiglottic elevator bar to protect/elevate epiglottis during ETT placement
  • Shorter, allows ETT to reach vocal cords
  • Permits ETT up to size 8
  • Wider bore accommodates pilot tube cuff during removal of LMA
  • ETT 'pusher/stabilizer' supplied with kit to ease removal of the ILMA

Disadvantages:

  • Bulky, with preformed curve, placement difficult in patients with limited mouth opening
air-Q® (also known as Intubating Laryngeal Airway and Cook Gas)

Click to enlarge.

Advantages:

  • Designed as intubating conduit
  • No aperture bars
  • Shorter, allows ETT to reach vocal cords
  • Accommodates conventional ETT
  • Can be left in situ during case which may be utilized during emergence
I-gel™

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Advantages:

  • Designed for intubating through
  • Esophageal port
  • No aperture bars
  • Shorter, allows ETT to reach vocal cords
  • Gel bowl does not require inflation

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Bronchoscopic intubation with assistance from a video laryngoscope

Combining a flexible bronchoscope technique with a video laryngoscope such as a GlideScope® overcomes the difficulty with the 'blind' part of the bronchoscopic technique and simultaneously provides tongue retraction. Usually, it is not possible to see the passage of the ETT through the laryngeal inlet over the bronchoscope. Any blind technique increases the risk of trauma and bleeding, especially in the population of patients requiring awake intubation who may have a friable tumor or infection. This is more applicable to patients having asleep bronchoscopic intubation, but can also be used in awake patients, in which case the video laryngoscope takes the place of the oral intubating airway.

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Continue to: Module 3: The Patient