Indian J. Anaesth.
RAMESH 2005; 49 AIRWAY
: FIBEROPTIC (4) : 293 - 299
MANAGEMENT
FIBEROPTIC AIRWAY MANAGEMENT IN
ADULTS AND CHILDREN
Dr. Ramesh S.
Introduction
The most common cause of mortality and serious
morbidity due to anaesthesia is from airway problems. It
is estimated that about one-third of all anaesthetic deaths
are due to failure to intubate and ventilate. The Flexible
fiberoptic endoscope is the most valuable single tool available
for the anaesthesiologist to manage the difficult airway.1
Flexible fiberoptic bronchoscopy is very useful for the
anaesthesiologist in the management of difficult tracheal
intubations, evaluation of the upper airway, verification of
endotracheal tube placement, repositioning or checking
patency of endotracheal tubes, changing endotracheal tubes,
placement of double lumen tubes and placement of
endobronchial blockers. The flexible fiberoptic intubation
bronchoscope gives the competent practioner the unparalled
opportunity to secure almost any difficult airway
encountered. The use of fiberoptic instruments to help in
airway management is a relatively a recent event. In 1967,
Dr.P.Murphy was the first to use a fiberoptic instrument
for the control of airway when he performed a nasal
intubation under general anaesthesia for a patient with
advanced still’s disease using choledochoscope.
Basis of fiberoptics
Light travels at different velocities in different
substances. The effect of each substance on light velocity
is indicated by the refractive index of the substance, which
compares the velocity of the light through the substance
with that through a vacuum. This difference in velocities
has the effect of altering the direction of a light beam as
it passes from one medium to another. If the light hits a
glass-air interface at 90 degree, it will pass straight through,
but at any other angle, as the light passes from the glass
to the air, its direction will be altered. As the angle of
incidence of the light is increased from the perpendicular,
the greater the bending of the light as it emerges from the
glass into the air. Eventually, there will be a point where
the light is reflected back inside the glass, almost as if it
had rebounded off a mirror. This is called ‘total internal
reflection’ and occurs at the ‘critical angle’ (fig. 1-2). It
becomes possible, therefore, to bounce light down the inside
of a glass rod from one end to the other.
M.D., Consultant Anaesthesiologist
Kanchi Kamakoti CHILDS Trust Hospital, Chennai
E-mail : paedsramesh@yahoo.com
293
Fig - 1 Fig - 2
Construction
The fiberoptic scope is a flexible instrument, which
is capable of transmitting an image from the distal tip to
the proximal end. The motion of the tip of the fiberscope
can be controlled which enables the operator to direct the
scope in any desired fashion. The combined characteristics
of controllability, flexibility and image transmission permit
anesthesiologists to employ the fiberscope as an aid to
tracheal intubation and as a therapeutic instrument.
The technological factor, which makes it possible to
use the flexible fiberscope, is the fact that a beam of light,
which enters an ordinary glass rod, is reflected off the
walls of the rod and emerges from the other end. Ideally
little light is lost in the process of reflection except due to
absorption. The fact that the property of total internal
reflection is maintained for glass fibers as small as 8 microns
makes it possible for fiberoptic technology to be used in
fiberoptic scopes.
Heating and stretching a glass rod permits the
formation of glass strands, which are less than 25 microns
in diameter. At this small size the glass becomes flexible
and is termed a fiber. Light, which enters one end of a
fiber, is repeatedly reflected off the walls of the fiber and
emerges at the other end with a uniform appearance.
Therefore, a single fiber is capable of transmitting light but
incapable of transmitting an image. To solve the problem
of image transmission an objective lens is placed at the tip
of the fiberscope. This lens focuses the image on a large
number of flexible fibers, which are tightly fastened together
at the proximal and distal ends of the scope. The fixed,
flexible bundle has the identical arrangement of fibers at
both ends of the scope, which permits the insertion cord to
be flexible, and allows the image to be transmitted through
the length of the scope. Without this organized, coherent
bundle and the optical insulation of each fiber, an image
could not be transmitted.
294 PG ISSUE : AIRWAY MANAGEMENT
In order to prevent degradation of the image each
fiber is coated with a transparent substance of lower
refractive index in a process called cladding. The cladding
aids in light transmission and optically insulates each fiber.
The image resolution is directly related to the size
of the smallest fibers. Since the lower limit for glass fiber
size is 8 microns images smaller than this cannot be
resolved. Details, which are smaller than this, cannot be
seen because the image quality is degraded by the multiple
reflections within a glass fiber. The image quality is also
directly related to the total number of fibers in the coherent
bundle. The image, which emerges at the handle of the
fiberscope, is focused by the eyepiece lenses and can be
viewed directly by the operator or can be transmitted with
a video camera to a television screen and / or video
recorder.
Another technology, which has been used to make
flexible scopes, is to place a video chip at the distal end
of the insertion cord and to focus the image from the
objective lens directly onto the video chip. This eliminates
the need for light transmission fibers and significantly
improves the image resolution. The limiting factor in using
this approach in intubating in intubating scopes is the size
of the video chip, which necessitates a larger diameter
insertion cord.
Fiberoptic bundles are used to transmit light from
an external light source to the distal tip of the scope. This
serves to light the field of view during endoscopy. Since an
image is not transmitted through these fibers there is no
requirement to arrange them in a coherent bundle.
The fiberscope (fig. 3) is composed of three parts a
body, a flexible insertion cord and a light transmission
cord. The body of the scope includes the tip deflection unit,
eyepiece. Focusing light, and working channel sleeve. The
insertion cord is the part of the scope, which is inserted
into the patient. It contains the working channel, one image
transmitting fiber bundle, and one or two light transmitting
bundles. The light transmission cord sends light from an
external source to the tip of the insertion cord, which
allows the field of view to be illuminated.
Fig - 3
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
Manipulation and handling the scope
The intubating fiberscope can be introduced through
the nose or mouth, advanced past the larynx, down the
trachea, and into the bronchi. Moving the scope into or out
of the patient controls the depth; rotation of the scope and
tip manipulations control the anterior / posterior, and side
motion.2 In order to maintain control of the tip it is absolutely
essential that the insertion cord be free of torque. Twisting
the insertion cord results in a loss of coordinated motion
between the control lever in the handle and the tip of the
fiberscope. Torsion of the scope can be prevented by holding
the control unit in one hand and keeping the insertion cord
stretched in a taut manner. If one wishes to deflect the tip
anteriorly or posteriorly the control lever is activated in
the desired direction. If one wishes to move the tip from
side to side the entire scope is rotated and maintained taut.
By keeping the scope stretched rotation which takes place
in the control handle is transmitted to the tip. This is
termed coordinated rotation and it is this process, which
allows one to maintain complete control of the tip direction.
Keep the insertion cord straight and taut and do not
form a loop
The fiberoscope is always best held with the insertion
tube straight (fig. 4,5). Do not form a loop (fig. 6). This
prevents accidental damage to the insertion tube and will
improve the control over the distal tip of the instrument
during endoscopy
Fig - 5
Fig - 4 Fig - 6
The distal tip can be moved up and down by moving
the lever on the control body up and down (fig. 7) but
remember that it works in reverse, i.e. when the lever is
pushed up, the tip will move downwards. The angle of
deflection can be upto 260 degrees depending upon the
instrument being used.
There is no mechanism in the fiberoptic bronchoscope
that can move the tip of the instrument from side to side.
So looking from side to side is little trickier. If the operator
wishes to look right (fig. 8), they must twist the control
body clockwise which is replicated at the tip and can view
the right. This is possible only if the insertion cord is kept
taught without forming a loop. So to look left the control
body is twisted anti-clockwise.
RAMESH : FIBEROPTIC AIRWAY MANAGEMENT
Fig - 7 : Upward and downward
Fig - 8 : Side-to-Side movements
of the distal tip
movement of the distal Tip
The forward and backward movement is accomplished
by pushing the scope in and out of the patient gently with
good lubrication. These movements should be gentle and it
should be like threading a thread into the eye of a needle
The working channel of the fiberscope is a hollow
tube from the handle to the distal tip of the insertion cord.
On intubating fiberscopes, depending on the model, the
working channel may be as small as 1.2 mm. Although it
was designed to permit suctioning of secretions and blood,
the working channel becomes clogged easily when it is used
this way. Insufflation of oxygen through the channel is
advantageous because it blows secretions away from the tip
of the scope and dries the tip. This serves to improve the
visualization of the structures of interest. Local anesthetics
can also be injected through the channel.
The fiberscope is a delicate instrument, which must
be handled with care. Dropping or crushing the handle,
light cord, or insertion cord can lead to severe damage
which is costly to repair. When performing oral fiberoptic
intubation it is helpful to use an intubating oral airway to
prevent the patient from biting the scope.
Technique of fiberoptic intubation3
Nasal intubation:
Fiberoptic intubation via nasal route is usually easier
and has a higher success rate compared with an oral
approach. This approach is also useful in dental and
maxillofacial procedure and in temporomandibular ankylosis.
The main advantage of nasal approach is a straight route
to larynx and trachea and the endotracheal tube passes
more easily.
Another benefit of the nasal approach is the stability
of the endotracheal tube once it has been secured in position.
The main problem of nasal intubation is bleeding which can
make the intubation difficult. One can pass the endotracheal
tube first into the nostrils and pass the fiberoscope through
the tube that is ‘tube first’ technique or glide the endotracheal
tube into the scope then pass the scope through the nostrils,
that is ‘scope first’ technique and finally once the scope is
inside the trachea slide the endotracheal tube. But during
295
tube first technique there are problems of traumatizing the
nasal passage and the manipulation of the tip of the scope
may be difficult.
Oral Intubation
An oral fiberoptic intubation succeeds less frequently
than nasal route because of the greater angle between the
oral cavity and the laryngeal inlet and trachea. It is also
more difficult to keep the insertion tube of the fiberoscope
in the midline using oral route. Certain oral fiberoptic
intubating aids like Ovassipian’s airway, Bermans airway
or Bite block can be used to aid oral fiberoptic intubation.
The basic steps of fiberoptic intubation
- Keep the insertion cord straight and taut and do not
form a loop
- Oxygenate through any possible route
- Antifogging to telescopic lens
- Push fiberscope very slowly and gently
- Enter the oropharynx (nasal or oral route)
- Identify the first land mark ‘the epiglottis’ (fig. 9)
- Advance the fiberoscope to the laryngeal opening
- Advance the fiberoscope until it enters the subglottic
space
- Identify the second landmark ‘the trachea’ (fig. 10)
- Advance it down slowly till you see the third landmark
‘the bifurcation’ (fig. 11)
- Advance the endotracheal tube with a gentle rotation
motion
- Remove the fiberoscope
- Verify the position and fix the endotracheal tube
Connect the anaesthesia circuit
Fig. 9 Fig. 10 Fig. 11
Awake or asleep
Awake intubation
If there is uncertainty whether the airway can be
maintained after the induction of general anaesthesia, then
tracheal intubation should be performed with the patient
awake. Some of the other indications of awake intubations
are if a patient is at a high risk of aspiration of gastric
contents, moribund and comatose patient and patient with
unstable cervical spine.
296 PG ISSUE : AIRWAY MANAGEMENT
Local anaesthetic techniques for awake intubation
Before applying any of the techniques described
below, the monitors should be attached to the patient and
an intravenous cannula must be inserted. The operator should
also have knowledge of the signs of local anaesthetic toxicity
and its treatment.
Nose and pharynx – Topical anaesthesia, lignocaine
spray or lignocaine nebulisation
Larynx and trachea – ‘spray as you go’ technique,
cricothyroid puncture and internal laryngeal nerve block.
Please remember when you use the combination of
above techniques, the total dose of the lignocaine should not
exceed 3.7 mgkg-1.
General anaesthesia
- No relaxant technique
- Relaxant technique
In order to train anaesthesiologists in fiberoptic
intubation you must develop a technique, which has the
following components:
• Achieves intubation in a reasonable time
• Maintains oxygenation and adequate ventilation
• Ensures anaesthesia is continued. Avoids unnecessary
use of drugs
• Allows assessment of the airway for subsequent post
operative safety. Allows rapid exit if required
• Can be used for nasal or oral intubation depending on
surgical needs.
It is important to teach a technique, which is basically
safe.4
General snaesthesia – No relaxant technique
Historically maintenance of spontaneous respiration
has been considered the safe approach in both adult and
paediatric practice when managing the patient with a difficult
airway. In adult practice the focus is on awake intubation
but achieving awake giberoptic intubation in young children
is difficult and therefore most fiberoptic intubation in
children with the child asleep. The goal of placement of an
endotracheal tube should be achieved while maintaining
safe control over airway and vital parameters.5
Once asleep there are many options on how to
maintain the airway and anaesthesia depending on whether
the nasal or oral route to intubation is required. Equipment
such as the LMA, use of a nasal prong or the airway
endoscopy mask will allow fiberoptic access to the airway
whilst respiration continues. The airway can then be
topicalised with local anaesthetic. The depth of anaesthesia
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
is increased and spontaneous respiration maintained. The
patient is fully monitored and closely observed.
Advancement of the fiberoptic scope is usually well
tolerated but finding the larynx and trachea is only part of
the story. As we know paediatricians and respiratory
physicians very successfully do bronchoscopies with “mild
sedation”, with the child breathing. However it is the
passage of the tracheal tube which is more difficult and
may, if not carefully achieved, result in laryngospasm,
coughing, displacement of the fiberoptic scope and loss of
the airway.
In order to pass a tracheal tube the cords need to be
well abducted so the question is how to ensure this. This
is a debate in the wider sphere of anaesthesia. Relaxants
are avoided by many anaesthetists in various situations and
there are increasing reservations on using paralysis during
routine tracheal intubation.
The advantages of no relaxant technique
• Increase in safety as the patient continues to breath,
maintaining oxygenation and anaesthesia.
• Easier maintenance of an adequate level of anaesthesia,
less risk of awareness.
• Whilst breathing continues there is less soft tissue
collapse, especially in the difficult child e.g.
rnucopolysaccharidoses, this provides a better view of
the larynx.
• Allows you to assess the airway and to modify your
technique and allows time for a gentle approach.
• During teaching allows you to watch the trainee rather
than the anaesthetist needing to ventilate the patient.
• Avoids effects of relaxants including anaphylaxis risk.
• Teaches a safe method.
• If fiberoptic intubation is unsuccessful then the patient
is still breathing adequately and if the “plan B” is a
tracheostorny or wake up, then you can readily change
to this plan having not made things much worse by
having a paralysed child whom you can’t intubate.
To achieve fiberoptic intubation requires deep
anaesthesia. This can be achieved with sevoflurane,
halothane, isoflurane, propofol or a combination of propofol
and inhalational agent and use of an effective strategy to
enable passage of the tube.
There are various alternative ways to achieve this,
which include
• Increase the inhalational agent
• Propofol
RAMESH : FIBEROPTIC AIRWAY MANAGEMENT
• Remifentanil
• Topical local anaesthetic
All are easily reversible or time limited so much
safer and work perfectly well
General anaesthesia–Relaxant technique
General anaesthesia plus neuro muscular block
(NMB) gives control to the anaesthesiologist and reliably
prevents laryngospasm, coughing and sudden patient
movement.6 Fiberoptic bronchoscopy often is easier after
complete NMB, and also advancement of the endotracheal
tube through the laryngeal entrance may be facilitated.
Loss of spontaneous ventilation is offset by oxygenation via
the working channel of the flexible fibroptic endoscope and
supportive ventilation. The time available for fibroptic
bronchoscopy is theoretically unlimited as long as ventilation
and oxygen are supplied and tissue injury avoided. Not
surprisingly, a number of authors have been quoted with
prolonged intubation times compared to conventional
intubation. But this applies for all fiberoptic intubation
techniques. It is the advantage of the relaxant method that
fiberoptic bronchoscopy may be interrupted to ventilate a
patient manually as indicated. Additionally, the use of either
a special airway endoscopy mask or a swivel adapter
connected to face or laryngeal mask even allows
simultaneous ventilation and fiberoptic intubation. Mask
ventilation during fiberoptic intubation effectively prevents
hypoxemia although intubation times are prolonged compared
to apnoeic patients.
While the use of a rigid laryngoscope blade may be
helpful in fiberoptic scopy, jaw thrust and the introduction
of an oropharyngeal airway or laryngeal mask may improve
both intermittent ventilation and endoscopic access to the
larynx, keeping the upper airway open. All these supportive
measures are facilitated by NMB.
It is mandatory to assure adequate ventilation with
a facemask before application of a muscle relaxant. In the
case of contraindications of mask ventilation, classical
situations where rapid sequence induction are preferred
techniques like ileus, severe regurgitation, full stomach-
fiberoptic intubation should be restricted to patients who
tolerate fiberoptic scope under conscious sedation or where
alternative airway techniques seem hazardous and inadequate.
Fiberoptic intubation during rapid sequence induction, with
cricoid pressure applied, has also been proposed but does
not respect the principle to assure mask ventilation first. Is
the coincidence of fiberoptic intubation, general anaesthesia
and risk of aspiration unavoidable, the value of each item
has to be weighed: The risk of asphyxia with deleterious
outcome has been judged much higher than the risk of
297
regurgitation and aspiration. So it is acceptable to mask
ventilate with cricoid pressure applied when intubation fails.
As we see many situations in daily routine at our institution
where cautious mask ventilation is feasible and has not lead
to adverse effects in spite of a relative risk of regurgitation,
we advocate that mask ventilation should always be
attempted before muscle relaxant application to facilitate
fiberoptic intubation in anticipated difficult airway situations.
The catastrophe of “cannot ventilate cannot intubate” has
to be prevented under all circumstances. After the feasibility
of mask ventilation has been demonstrated, NMB will, on
the other hand, prevent active vomiting, another advantage
compared to spontaneously breathing patients.
General contraindications of muscle relaxants
have to be respected. Mediastinal masses may be a
contraindication for NMB to avoid tracheal collapse. Once
the trachea has collapsed flexible fiberoptic intubation is
hardly useful, thus different approaches have to be assessed.
Pediatric fiberoptic bronchoscopy
Though above techniques can be used in children
also everyone may not be able to procure all the sizes of
bronchoscope possible. So different techniques of fiberoptic
intubation is described with the use of bigger size scope for
passage of smaller size tube.
Ultra thin fiberoptic bronchoscope
The 2.2 mm ultrathin fiberoptic bronchoscope is now
available; permitting passage through a 3.0 mm endotracheal
tube (ETT).This model does not have a suction port, but
does have a flexible tip (120°). Both oral and nasal routes
may be used. During nasal bronchoscopy, passing the
fiberoptic bronchoscope through the nares and keeping the
ETT proximally is preferred. The fiberoptic scope is
manipulated, vocal cords visualized, and the trachea entered.
After visualization of the carina, the ETT may be passed
over the Fiberoptic scope and position confirmed on
withdrawal of the Fiberoptic bronchoscope. This technique
is the same as for larger fiberoptic scope/endotracheal tube
used in older patients. Direct visualization and passage into
the trachea by the fiberoptic scope is the preferred method!!!
Fiberoptic bronchoscope with suction channel
This utilizes a Fiberoptic bronchoscope too large to
pass directly into the patient’s trachea, a technique.
Equipment needed includes a fiberoptic bronchoscope with
a suction channel, a teflon coated flexible guide wire (.038"
x 145 cm), a cardiac catheter (7 Fr =.038" x 65 cm) with
the luer lock hub removed, an ETT, and a skilled assistant.
Prior to starting, ensure that the flexible guide wire easily
slides through the suction port of the fiberoptic bronchoscope,
that the cardiac catheter moves over the guide wire, and
298 PG ISSUE : AIRWAY MANAGEMENT
that the ETT chosen fits over the cardiac catheter. Thread
the guide wire through the suction port to the point just
proximal to the flexible tip. The fiberoptic bronchoscope is
then introduced into the patient, and the vocal cords
visualized. The endoscopist then instructs the assistant to
advance the guide wire slowly, while the endoscopist
watches the wire pass through the cords. The guide wire
may be advanced until it meets slight resistance (the
bronchus). The fiberoptic bronchoscope is gently removed
while the guide wire is held in place. The patient may be
mask ventilated with the wire in place, if necessary. The
tip of the ETT may get caught on epiglottis or aryepiglottic
folds if the ETT is directly threaded over the guide wire,
resulting in kinking and withdrawal of the wire from the
trachea. By threading the cardiac catheter onto the guide
wire (again until slight resistance is encountered), the ETT
has a firmer guide and less chance of deviation with
advancement.
Fiberoptic bronchoscope visualization. The “not-so-
blind blind nasal” technique7
This utilizes a fiberoptic bronchoscope too large to
pass directly into the patient’s trachea. An ETT is passed
through one nares while a fiberoptic bronchoscope is passed
through the other nares. Under fiberoptic bronchoscope
vision, the nasal ETT is manipulated into the trachea. An
assistant may provide head extension or elevation, tracheal
pressure, or other maneuvers as determined by the endoscopist.
Laryngeal mask airway (LMA).
The LMA can be used to ventilate the patient as
well as provide a guide for fiberoptic and endotracheal tube
guidance into the trachea. When the LMA is correctly
placed, the trachea lies directly ahead when advancing the
FOB past the web of the LMA. Note the equipment
limitations of the various size LMAs.
LMA size # ETT mm FOB mm
1 3.5 2.2
2 4.5 3.5
2.5 5 4.0
3 6 cuff 5.0
4 6 cuff 5.0
Problems faced during fiberoptic intubation
1. Poor vision
- Inexperience
- Poorly focused eyepiece
- Film over the lens
- Fogging
- Secretions and blood
- Touching the mucosa (red out)
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
2. Bleeding
3. Coughing
4. Desaturation
- Respiratory depression due to drugs
- Excessive use of suction
- Endobronchial intubation
- Loss of airway
5. Laryngospasm and bronchospasm
6. Oesophageal intubation
7. Failure to railroad the endotracheal tube (‘hang ups’)
- use the nasal approach
- Use the correct size endotracheal tube (not too
large, not too small)
- if hang-up occurs – pull back and twist the ETT and
do some external digital manipulations
How to learn fiberoptic Intubation
- Attend fiberoptic intubation workshops
- Practice on mannequin
- Practice on models.
- Practice on the normal patients
Cleaning and disinfection
Cleaning
Of all infection control measures, thorough cleaning
of the equipment is of the greatest importance. Immediately
after use, the suction channel should be rinsed with water
or saline to remove blood, tissue, and secretions. As soon
as possible, mechanical cleaning, i.e. wiping of the outside
of the bronchoscope and brushing of all channels with a
detergent solution should be performed to prevent drying
of secretions. Subsequently, the outside of the endoscope
and the suction channel should be extensively rinsed with
high-quality tap water and then dried by wiping with dry
gauze and by suctioning. The removed and disassembled
suction valve should be cleaned with a brush and detergent
solution thoroughly, then rinsed and dried. Additional items
of equipment like cameras, remote video controllers, light
sources, and procedure carts should be regularly wiped
with 70% alcohol.
Disinfection
After each examination, and before re-use,
disinfection of the bronchoscope, aiming at the elimination
of all organisms and viruses and of most bacterial and fungal
spores, must be performed. Two per cent alkaline
glutaraldehyde is the disinfectant of choice for flexible
endoscopes: immersion for 20 min is considered sufficient
to kill virtually all pathogens surviving on a well-cleaned
bronchoscope. As efficacy of any disinfecting or sterilising
agent can only be assumed when microorganisms are
RAMESH : FIBEROPTIC AIRWAY MANAGEMENT
exposed directly to the agent, increasing the period of
disinfection does not compensate for inadequate cleaning.
Glutaraldehyde and other disinfecting agents may be
extremely irritating to the airway mucosa. Thus, disinfection
must be followed by adequate rinsing of the instruments
with sterile deionized water to remove all traces of the
disinfectant. Subsequently, the insertion tube should be wiped
and the channel and the suction valve rinsed with 70%
alcohol and then dried. Alcohol is not only a powerful
antimycobacterial agent, but also facilitates drying. Finally,
the bronchoscope should be stored in a clean environment.
Sterilisation
Sterilisation means the complete elimination of all
viable organisms, including fungal spores. Flexible endoscopes
are damaged by conventional heat sterilising methods. Gas
sterilisation with ethylene oxide at temperatures <55°C is
safe, but not always practical because of the extended time
needed to complete the sterilisation process. Furthermore,
the recommended aeration time of 10–12 h severely restricts
the availability of the bronchoscope. Thorough cleaning and
drying of the bronchoscope must precede gas sterilisation.
Damaged endoscopes have to be gas sterilised, as soaking
ANAESTHESIA PNEUMONICS / ACRONYMS FOR EASY REMEMBRANCE
Lemon Law (Walls, 2000)
1) Lemon represents 5 simple, reproducible and rapid
assessment methods on unco- operative and co-operative
patients.
L – Look to identify features suggesting difficulty.
E - Examine the airway using measures (3-3-2 rule)
M – Mallampati grade
O – Obstruction - Location, type and progression
N – Neck mobility.
3-3-2 rule:
3 – 3 fingers mouth opening.
3 – 3 fingers between mentum and hyoid bone
2 – 2 fingers between top of thyroid cartilage and
mandible (floor of the mouth)
2) BONES :- assessment of difficult mask ventilation.
B – Bearded individual
O – Obesity (BMI > 26 kgm-2)
N – No teeth
E – Elderly (age > 55 years)
S – Snorer (Patients having 2 or more of these
predictors are likely to have difficult mask ventilation)
299
the instrument will cause further damage. Even after a
30 min exposure to 2% glutaraldehyde the spring-operated
suction valves may remain contaminated; thus, it is suggested
that removable, heat-stable parts like suction valves should
be steam autoclaved after cleaning. Nondisposable accessories
should be steam sterilised, if applicable. The manufacturers’
guidelines should always be consulted and adhered to.
References
1. Ovassapian A. Fiberoptic tracheal intubation in adults. In: Ovassapian
A, ed. Fiberoptic endoscopy and the difficult airway. Philadelphia:
Lippincott-Raven 1996.
2. Popat M. Practical fibreoptic intubation. Oxford: Butterworth-Heinemann,
2001.
3. Stackhouse RA. Fiberoptic airway management. Anesthesiology Clin
North Am 2002; 20: 930-951.
4. Soodan A, Pawar D, Subramanium R. Anesthesia for removal of inhaled
foreign bodies iii children. Pediatric Anesthesia 2004; 14: 947-952.
5. Erb T, Hampi KF, Schürch M, Kern CG, Marsch SCU. Teaching the
use of fiberoptic intubation in anesthetized, spontaneously breathing
patients. Anesth Analg 1999; 89: 1292-1295.
6. Practice guidelines for the management of the difficult aiiway: An updated
report by the American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Anesthesiology 2003; 95: 1269-1277.
7. A. Arul DA, R. Jacob MD, DA. A different under vision approach to
a difficult intubation. Paediatric Anaesthesia 1999; 9(3) 260.
3) All Amides Local Anaesthetic agents have in
general two “i” in their spelling viz.
Lignocaine, Bupivacaine, Dibucaine, Priilocaine,
Ropivacaine, Etidocaine.
All esters local anaesthetic agents have only one
‘i’ in their spelling viz.
Cocaine, Procaine, Chloroprocaine, Tetracaine,
Benzocaine
4) Mapleson circuits ranked in order of efficiency for
institution of Spontaneous or Controlled Ventilation :
Controlled Ventilation
D-B-C-A : Dead Body Cannot Argue
Spontaneous Ventilation
A-D-C-B : All Dogs Can Bite
Dr. Nibedita Pani
Bhubaneshwar
GC Member, ISA