Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions.

Fibreoptic tracheal intubation is a useful technique in patients whose tracheas are dif®cult to intubate. 69 However, there are two major dif®culties with this technique. The ®rst is location of the glottis and insertion of a ®brescope into the trachea. Induction of general anaesthesia (with or without neuromuscular block) causes the soft palate, tongue and epiglottis to approximate to the posterior pharyngeal wall, and thus little air space is left in the oropharynx for manoeuvring the tip of the ®brescope to locate the glottis. The second dif®culty is insertion of a tube over the ®brescope into the trachea. There have been reports of failed tracheal intubation despite successful insertion of a ®brescope into the trachea. 89 To solve the ®rst dif®culty, several manoeuvres (such as thrusting the jaw forward, extension of the head, or traction of the tongue) have been proposed, and airway intubators (such as the Berman, Ovassapian and Williams) have been developed. In addition, there have been comprehensive articles discussing effective ways of teaching ®brescopy. 66 69 85 In contrast, there have been no textbooks or reviews which comprehensively deal with the second dif®culty, of advancing a tracheal tube over a ®brescope. Therefore, the main aim of this review article is to analyse the incidence of, causes of and possible solution to, the dif®culty in advancing a tube over a ®brescope into the trachea.