FIBEROPTICALLY GUIDED ENDOTRACHEAL INTUBATION OF NEUROSURGICAL PATIENTS

Patients with cervical spine injury presenting with respiratory distre ss require airway management that does not compromise integrity of the atlanto-occipital joint. Endotracheal intubation by means of direct l aryngoscopy is not suitable. The method of choice is nasotracheal intu bation of the awake patient, using a flexible fibre bronchoscope. If a natomy or surgical access render the nasal approach impossible, fibre optic intubation can be performed orotracheally, utilising specific te chnical aids. Flexible fibrescopes are available in different sizes (l ength and diameter): selection is base on the patient's anatomical req uirements. Aids to orotracheal intubation are constructed with a bore wide enough to accommodate an endotracheal tube, and a face mask equip ped with an extra intubation port allowing introduction of an endotrac heal tube, slipped over a fibrescope. Premedication of the patients co nsists of an orally administered benzodiazepine. Topical anaesthesia a nd vasoconstriction of the nasal passages are achieved by cocaine (5-1 0 %), or a local anaesthetic, combined with a vasoconstrictor. The sel ected nostril is prepared by means of introducing a nasopharyngeal air way, which - lubricated with xylocaine gel and left in place for few m inutes - widens the nostril and facilitates passage of the endotrachea l tube. Through the other nostril, oxygen is administered. Systemic an algo-sedation is strictly limited to fentanyl, 0.1 mg i.v. Topical ana esthesia of the larynx and cranial trachea is achieved by xylocaine, 2 %, administered under direct vision through the instrumentation chann el of the fibrescope. Fibre-optically guided nasotracheal intubation o f the awake patient may be performed in all age groups, including infa nts, because endoscopes are now available with a diameter as small as 2.2 mm at the distal tip. Fibre optic endoscopic nasotracheal intubati on of the awake patient is the method of choice whenever direct laryng oscopy is to be avoided.