This Skill Station covers:
Navigating the upper and lower airways
Airway topicalisation
Practice on manikins and the Orsim™ bronchoscopy simulator
Main uses of the bronchoscope in airway management
- Oral/nasal awake or asleep bronchoscopic intubation in known difficult airways
- Plan B techniques (see Plan B module)
- Nasendoscopy for airway assessment (see Airway Assessment module)
The Ambu aScope 4 Broncho is used on the CCAM and CCAM Essentials courses and so its details are featured here.
It is a single use video bronchoscope containing no fiber-optic technology. Several other single use and multi-use bronchoscopes are available.
Modern bronchoscopes use an LED as the light source and a digital camera to capture images rather than fiber-optic technology. They are therefore correctly called videobronchoscopes rather than fiber-optic bronchoscopes, although the latter term is still often used.
Most bronchoscopes are 55-60cm in length and are available in 1.8 – 6.4mm diameters. The most commonly used bronchoscopes for airway management are 4-5mm in diameter.
Higher diameter scopes have larger working channels but are more difficult to manipulate and cause more trauma.
Ambu aScope 4 Broncho™
Ambu aScope 4 Broncho™
Acquiring the manual dexterity for bronchoscopic intubation is a demanding process. A learning curve involving 45 bronchoscopic intubations has been suggested to achieve expert level.
The good news is that supervised practice on simple airway models has been shown to accelerate the learning of the skills required.
On the CCAM and CCAM Essentials courses, we have anatomically accurate models and a virtual reality bronchoscopic trainer, the Orsim™, which allows learners to navigate normal and abnormal airway and bronchial anatomy, and contains many difficult airway and pulmonology scenarios all within a safe, virtual environment that provides objective scoring and instant feedback.
There are four main components to successful nasendoscopy and bronchoscopy:
- Topicalisation (see below)
- Other drugs (consider anti-sialagogues, analgesia/sedation, e.g. remifentanil)
- Communication with the awake patient
- Good motor skills
Top Tips
- Get an assistant to apply jaw thrust to increase space in posterior pharynx
- Always maintain a straight scope
- Orientate yourself using anatomical landmarks
- Aim for black, rotate scope to bring target into flexion plane (between 6 and 12 o’clock), then advance towards target by flexing / extending
- Keep target in the centre of the field of vision
- If you see red, withdraw until re-orientated, don’t push further
- Failure to negotiate nares – ensure good topicalisation, check nostril patency beforehand
- If intubating:
- Don’t advance tube too early – advance bronchoscope to carina before carefully advancing tube
- Rotate tube 90° anti-clockwise to prevent bevel catching on cords (Bronchoscope Left Turn – BLT).
Topicalisation refers to the application of topical local anaesthetic agents and vasoconstrictors prior to nasendoscopy and bronchoscopy.
This has three main aims:
- patient comfort
- decreased coughing and gagging
- decreased bleeding.
There are many recipes and methods available for airway topicalisation, below is a summary of the better options.
Remember, topicalisation takes time – don’t rush it.
MADjic™ Nasal
MADjic™ Nasal
- Atomiser
- For nasal use
- Attach to syringe
- Inexpensive
MADjic™ LT
MADjic™ LT
- Atomiser
- Attach to syringe
- Laryngotracheal use
- Inexpensive
DeVilbiss
DeVilbiss
- Atomiser
- Oxygen driven
- Nasotracheal use
- Single use available
"Chook's foot"
"Chook's foot"
- “Home made”
- Multi-port IV line
- Oxygen driven
- Nasotracheal use
