Cannot be used in awake patients; therefore used when Awake Intubation is not appropriate or infeasible (e.g. agitated, non-cooperative or obtunded patient) and:
Anticipated difficult intubation due to difficulty getting to or through the vocal chords (e.g. anterior larynx, crowded pharynx, obstructing or friable supraglottic lesions) i.e. problem is above the cords or
Failed intubation due to:
Video laryngoscopy fails
Flexiscopy is difficult
Contra-Indications
Situations where awake intubation is indicated (e.g. suspected or known difficult airway in a cooperative patient)
Extremely limited oral access (e.g. severe trismus) preventing use of a laryngoscope
Inability to pass bronchoscope (e.g. gross contamination, severe bleeding)
Method
Videolaryngscopy with a hyperangulated blade is inserted to:
Displace soft tissues
Open the airway
Create a pathway to the laryngeal inlet
A flexible bronchoscope (with preloaded ETT) is used as a steerable bougie
Identify vocal cords and advance flexiscope into trachea
Confirm endotracheal location by identification of tracheal rings, trachealis muscle and carina
Railroad ETT over scope
Rotate ETT anticlockwise (“left turn”) when advancing between the vocal cords to avoid the bevelled tip of the ETT catching on the arytenoids
Once ETT positioned, remove flexiscope while stabilising the ETT