A 27-year-old patient presents to the emergency department after a motor vehicle accident. He was taken out of a crumpled car. Emergency medical services reported that he was conscious when they arrived. On arrival, he has pain and swelling in the jaw area. During examination his mental status deteriorates, the swelling increases, and breathing becomes labored.
Should this patient be intubated? If so, how?
This patient should be intubated for several reasons. First, there is an alteration of mental status. Second, there is an injury of unknown severity, which may include the upper airway. Third, evaluation of the patient may involve both nonsurgical and surgical approaches, both of which would require relative immobility; airway control increases the safety of pharmacologic sedation. Fourth, agitation could lead to significant changes in intracranial pressure in this individual with an undefined intracranial status. Intubation ensures a secure airway. Failure to establish a secure airway can be the cause of significant morbidity related to airway injuries, hypoxemia and hypoxic brain injuries,1 severe hypotension, and frank aspiration.2 It can also result in death if associated with difficulty in ventilating the patient “noninvasively.”3
Bronchoscopic intubation is the method of choice in a case such as this. When being secured, the airway in a critically ill patient should always be considered to be a “difficult airway,”4 and bronchoscopy can facilitate intubation. In the scenario depicted above, there is a potential upper airway obstruction and there is a potential spinal injury; bronchoscopic intubation is strongly indicated. The capacity for bronchoscopic intubation cannot be an afterthought. Every institution should have in place an established protocol for management of the difficult airway, including access to equipment and expertise.4
The safety benefit from bronchoscopic intubation lies in the flexibility of the scope. Whereas with routine intubation a direct visual line to the vocal cords must be established, the bronchoscope can maintain visualization while following the arc to the posterior pharynx. The bronchoscope can be conformed to the body rather than conforming the body to a visual need, and when the bronchoscope is used the jaw thrust and manipulation of the head and neck are not required.
What is the method of bronchoscopic intubation?
Bronchoscopic intubation utilizes the scope as an introducer. Prior to bronchoscopy, an endotracheal tube (ETT) is preloaded onto the hilt of the bronchoscope. The bronchoscope is lubricated and passed through the vocal cords to the midtrachea. The preloaded endotracheal tube can then be passed over it. If resistance is met at the level of the larynx, rotating the ETT 30 to 90 degrees can change the position of the tube and facilitate its advancement through the vocal cords.
Endotracheal intubation via bronchoscopy offers another major benefit: visual confirmation both of placement within the trachea and of position. All other methods ...