Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions Asai T. , Shingu K. British Journal of Anaesthesia

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Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions Asai T. , Shingu K. British Journal of Anaesthesia Volume 92, Issue 6, Pages 870-881 (June 2004) DOI: 10.1093/bja/aeh136 Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 1 Incidence (and 95% confidence interval) of difficulty in advancing a tracheal tube over a fibreoptic bronchoscope. British Journal of Anaesthesia 2004 92, 870-881DOI: (10.1093/bja/aeh136) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 2 A precurved tube is advanced over a fibrescope and held with its greater curvature facing down. The bevel of the tube is facing the left and the tip of the tube is on the right. Thus the tip of the tube is more likely to impinge on the right arytenoid cartilage than the left. British Journal of Anaesthesia 2004 92, 870-881DOI: (10.1093/bja/aeh136) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 3 Schematic illustration of oesophageal intubation after correct insertion of a fibrescope into the trachea. (a) If the tip of a tracheal tube enters the oesophagus, the fibrescope is looped over the interarytenoid notch and over the tube tip. Resistance may be felt when advancing the tube because its tip is pushing the mid‐segment of the fibrescope into the oesophagus. (b) As the tube is inserted deeper into the oesophagus, the fibrescope is pulled out of the trachea into the oesophagus. British Journal of Anaesthesia 2004 92, 870-881DOI: (10.1093/bja/aeh136) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 4 If the tip of a fibrescope is inadvertently advanced though a side hole (Murphy eye) of a tracheal tube, it becomes impossible to advance the tube into the trachea. British Journal of Anaesthesia 2004 92, 870-881DOI: (10.1093/bja/aeh136) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 5 Insertion of a thinner tracheal tube between a larger tracheal tube and a fibrescope facilitates smooth passage into the trachea. British Journal of Anaesthesia 2004 92, 870-881DOI: (10.1093/bja/aeh136) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 6 (a) The Parker Flex‐Tip™ tracheal tube and (b) the intubating laryngeal mask airway tube. British Journal of Anaesthesia 2004 92, 870-881DOI: (10.1093/bja/aeh136) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions

Fig 7 When a tracheal tube is advanced over a fibrescope, the bevel of the tube is facing the left and thus the tip of the tube is liable to impinge on the right arytenoid cartilage or the right vocal cord (Fig. 2). When the tube is rotated 90° clockwise (a), the tip of the tube lies posterior to the fibrescope, and may impinge behind the arytenoid cartilages. In contrast, 90° anticlockwise rotation of the tube brings it into close contact with the fibrescope, minimizing impingement (b). When the tube is rotated 180°(c), the tip of the tube is liable to impinge on the left arytenoid cartilage or the left vocal cord. British Journal of Anaesthesia 2004 92, 870-881DOI: (10.1093/bja/aeh136) Copyright © 2004 British Journal of Anaesthesia Terms and Conditions