Introduction

This module covers the additional equipment utilized in a bronchoscopic intubation. The bronchoscope (module 1) and equipment for applying local anaesthesia (module 4) are covered elsewhere.

Endotracheal Tube (ETT)

The choice of ETT depends on the intended site of intubation (oral vs. nasal), intended duration of intubation, availability and operator preference.

Size

The ETT should be large enough to fit over the chosen bronchoscope but small enough to pass through the nasopharynx (for nasal intubation). A smaller ETT is less likely to be difficult to advance over the bronchoscope as this avoids a size discrepancy between bronchoscope and ETT. Size 6 – 7mm is suitable for most adults. A smaller diameter ETT may be shorter, which should be taken into consideration for nasal intubation.

ETT Choices

The table below outlines several choices of endotracheal tubes with their advantages and disadvantages.

Type of ETT	Nasal/Oral?	Description	Advantages & Disadvantages
Nasal RAE (Ring-Adair-Elwyn), "north facing"	Nasal	Click to enlarge.	Advantages: Length Ability to keep away from the surgical field without kinking the tube The bend sits comfortably just outside the nares Disadvantages: Potential difficulty navigating the bronchoscope through the preformed curve
Armored ETT	Nasal or Oral	Click to enlarge.	Advantages: Less nasal trauma Easier passage through the nose due to flexibility Disadvantages: May be unacceptable to ICU for post-op care May be too short to reach vocal cords when used for nasal intubation in some patients
Intubating LMA ETT	Nasal or Oral	Silicone, hemispherical bevel, with softer and more flexible tube Click to enlarge.	Advantages: Lower incidence of difficulty advancing the ETT over the bronchoscope Disadvantages: Not always available More expensive; choice of single-use or re-usable products Potential for kinking May be too short to reach vocal cords when used for nasal intubation in some patients Non compliant cuff May be unacceptable to ICU for post-op care
"Standard" PVC tube	Nasal or Oral	Click to enlarge.	Advantages: Widely available Most acceptable to ICU for post-operative care Disadvantages: May be too short to reach vocal cords when used for nasal intubation in some patients Increased chance of nasal trauma
Parker Flex Tip™ ETT		Tapered tip Click to enlarge.	Advantages: Lower incidence of difficulty advancing the ETT over the bronchoscope Disadvantages: Not always available More expensive

Back to Top of Page

Oral Intubation Devices

Several devices assist with oral bronchoscopic intubation, with the aims of:

• providing a passage for the scope
• protecting the scope should the patient bite down
• ensuring the scope is midline
• holding the tongue forward

Berman Airway

The Berman airway can be opened wide to disengage it from the ETT. Because it is quite long, if it is not in line with the glottis, passing the bronchoscope into the larynx can be challenging as the bronchoscope cannot be manoeuvred within the Berman airway. Withdrawing the airway partially can help.

Williams Airway

The Williams airway comes in two sizes: 90mm (accommodates an ETT size 8) and 100mm (accommodates ETT size 8.5). It requires removal of the 15mm connector from the ETT prior to removal of the airway. Similarly to the Berman, if it is not lined up with the glottis, manoeuvring the bronchoscope within the airway is difficult.

Ovassapian Airway

The Ovassapian airway comes in one size (accommodates ETT up to size 8.5). It can be 'opened' wide to disengage it from the ETT. It has a flat lingual portion to minimize movement from the midline and the open space assists with manoeuvring the bronchoscope.

Back to Top of Page

Aintree Catheter

When loaded on the bronchoscope, only the distal 3-4cm of the bronchoscope protrudes from the end, allowing manoeuvring. The pediatric size bronchoscope is placed in the lumen of the Aintree catheter. Both devices are then placed together – via a supraglottic airway or oral intubating device or via the nose. The bronchoscope is removed and the endotracheal tube is then railroaded over the Aintree catheter.

Video: ETT railroaded over Aintree catheter.

Back to Top of Page

Continue to: Module 2: Advanced Knowledge