Multiple Sites of Impingement of a Tracheal Tube as it is Advanced over a Fibreoptic Bronchoscope or Tracheal Tube Introducer in Anaesthetized, Paralysed Patients

Abstract

Impingement of the tracheal tube on upper airway structures occurs commonly during advancement over a fibreoptic bronchoscope or introducer. In this descriptive study a fibrescope was used to assess the site and mechanism of tracheal tube impingement during advancement over a variety of fibreoptic bronchoscopes and introducers during orotracheal intubation in anaesthetized adults. The effect of the 90° counterclockwise rotation manoeuvre in overcoming impingement was also assessed. We recorded impingement at the right arytenoid, left arytenoid, epiglottis, interarytenoid tissue and the left pyriform fossa. Our study found a wider range of sites at which impingement may occur than in previous studies. We also found that when 90° counterclockwise rotation of the tip of the tracheal tube was achieved, the impingement was reliably overcome.

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

“… 123 ‘Hold-up’ at the arytenoids is a feature of the left-facing bevel of most tracheal tubes, and can occur particularly whilst railroading larger tubes over a bougie, stylet, or fibrescope. 124 125 This problem can be overcome by rotating the tube anticlockwise to change the orientation of the bevel or by preloading the tube so that the bevel faces posteriorly and by minimizing the gap between the fibrescope and the tube during fibre-optic intubation. 125 – 127 Tubes with hooded, blunted, or flexible tips, such as the Parker Flex-Tip™ (Parker Medical), and tubes supplied with the Intubating LMA ® (Teleflex Medical Europe Ltd) have been designed to reduce the incidence of this problem.…”

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults

“…Sometimes, the endotracheal (ET) tube may get held up at the arytenoids leading to difficulty in the passage of the tube,[3435] especially while railroading the ET tube over a bougie, stylet or bronchoscope. This may be overcome by rotating the ET tube anticlockwise to change the direction of the bevel, keeping the bevel facing posteriorly while pre-loading the tube or by reducing the space between the bronchoscope and the ET tube.…”

“…This may be overcome by rotating the ET tube anticlockwise to change the direction of the bevel, keeping the bevel facing posteriorly while pre-loading the tube or by reducing the space between the bronchoscope and the ET tube. [343536]…”

Comparison of laryngeal morbidities with modified reinforced silicone tube intubation guided over a bougie vs. a guidewire: novel assessment with voice analysis

“…Flexible, semi‐rigid tracheal tube introducers and bougies are commonly used when difficulty is encountered in securing the airway during laryngoscopy with a tracheal tube . However, when used in patients whose tracheas were difficult to intubate, impingement of the tip of the tracheal tube at the glottis, arytenoids and the periglottic area can occur and lead to failure to intubate . In addition, cross‐contamination reported with re‐usable introducers has led to a surge of stiffer disposable ones, leading to a higher incidence of tracheobronchial injuries, especially if signs of ‘tracheal clicks’ and ‘hold‐up’ are elicited .…”