Laryngoscope & Fibreoptic bronchoscope

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Laryngoscope & Fibreoptic bronchoscope:

Laryngoscope & F ibreoptic bronchoscope Bikram Gupta

The upper airway:

The upper airway

The lower airway:

The lower airway

The airway reflexes:

The airway reflexes The aforementioned nerves participate in several brainstem-mediated reflex arcs. 1.gag reflex – triggered by mechanical and chemical stimulation of areas innervated by the glosso -pharyngeal nerve, and the efferent motor arc is provided by the vagus nerve and its branches to the pharynx and larynx. 2.glottic closure reflex – elicited by selective stimulation of the superior laryngeal nerve, and efferent arc is the recurrent laryngeal nerve. – exaggeration of this reflex is called laryngospasm . 3.cough – the cough receptors located in the larynx and trachea receive afferent and efferent fibers form the vagus nerve .

Definitions of Laryngoscopy:

Definitions of Laryngoscopy The first laryngoscope was invented in 1854 A laryngoscope (larynx + scope) is a medical instrument. That is used to obtain a view of the vocal folds and the glottis, which is the space between the cords is called laryngoscopy .

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TYPES OF LARYNGOSCOPY There are two types of laryngoscopy ; 1- Direct laryngoscopy 2- Indirect laryngoscopy

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Why We Do Laryngoscopy ? To facilitate tracheal intubation for mechanical ventilation during general anesthesia or cardiopulmonary resuscitation For procedures on the larynx or other parts of the upper tracheobronchial tree. Suction Foreign body removal Vocal cord function

Laryngoscope:

Laryngoscope The conventional laryngoscope consists of :- - a handle containing batteries with a light source - a set of interchangeable  blades. Handle – short handles may be effective :- - patients in whom the chest and/or breasts contact the handle during use - when cricoid pressure is being applied - when the patient is in a body cast.

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Parts of Laryngoscope

Laryngoscope blades :

Laryngoscope blades The blade is composed of several parts including the base, heel , tongue(spatula),flange, web, tip and light source. Two basic styles of laryngoscope blade are currently commercially available: the curved blade and the straight blade. Early laryngoscopes used a straight "Magill Blade", however the blade is difficult to control in adult humans and can cause pressure on the  vagus nerve, which can cause unexpected cardiac arrhythmias  to spontaneously occur in adults . straight blades are favored in patients who have a small displacement space (namely a small distance from the chin to the thyroid cartilage), since this is the area the tongue gets pushed into during direct laryngoscopy . Examples of such patients are small children (below the age of 8, but especially below age 5) and adults who have a receding chin.

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There are many other styles of curved and straight blades (e.g., Phillips, Robertshaw , Sykes, Wisconsin, Wis-Hipple , etc.) with accessories such as mirrors for enlarging the field of view and even ports for the administration of oxygen. The Miller, Wisconsin, Wis-Hipple , and Robertshaw blades are commonly used for infants. It is easier to visualize the glottis using these blades than the Macintosh blade in infants, due to the larger size of the epiglottis relative to that of the glottis.

Size markings for laryngoscopes:

Size markings for laryngoscopes 000 – small premature infant 00 - premature infant 0 - neonate 1 - small child 2 - child 3 - adult 4 - large adult 5 - extra-large adult

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Laryngoscope bulbs can be made with an incandescent filament (tungsten with halogen gas), xenon gas, or from a light emitting diode (LED). The bulb itself can have either a frosted or clear lens, and sometimes also includes a specialized reflector (common with bulb-on-handle designs). Compared to other light producing systems, LED bulbs use very little energy, operate with less heat, and have a much longer life span.

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With bulb-on-handle systems a light conducting fiber, conveys the light from the top of the handle to the distal portion of the blade. Although such blades are often called “fiber-optic,” they have no optical fibers, per se, and a more appropriate term is “fiber-lit”.

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Regardless of the light type, the intensity of light reaching the distal end of a laryngoscope is dependent on the distance from the light to the distal tip. This phenomenon is governed by the inverse-square law of physics if the distance from the light source to an object is doubled, the resultant amount of light energy reaching the object is reduced to one quarter of the original amount.  Blade designs with a shorter light-to-tip distance create more intense distal light.

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The Wisconsin blade with a straight spatula and flange that extends slightly toward the distal portion of the blade. The distal portion of the blade is wider and formed slightly to the right to better adapt it to lifting the epiglottis.

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A modification of the Wisconsin blade with a straight flat spatula tip and a large circular flange.

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A modification of the "English" style MacIntosh laryngoscope blade. A channel in the blade provides a means through which an endotracheal tube may be inserted after visualizing the cords. The anterior flange has been reduced to decrease the force upon patient's maxillary incisors. A new parabolic reflector lamp provides four times more light.

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While retaining the extended curved tip to facilitate lifting the epiglottis, the Cranwall ™ blade has dramatically reduced the flange to allow insertion through a restricted opening and decreases the potential for damage to the upper teeth. This blade has the flange removed directly below the light carrier

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The Phillips blade integrates the preferred straight Jackson blade design with the curved distal tip Miller design providing greater visibility and an almost direct line approach to the trachea during intubation. Unique lamp mounting provides deep illumination downward and inward, while the low profile flange reduces the risk of oral damage.

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The basic portion of the blade makes an angle of 135° with a stainless steel mirror located at that angle on the flange facing the spatula. The distal portion of the blade is three inches long. Because the mirror inverts the reflected image, the operator should exercise caution until familiar with its use. A curved stylette is recommended for use with the Siker blade. Placing the blade in a warm water bath for ten minutes before use will avoid any mirror fogging problems.

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A modification of the Wisconsin blade with a reduced flange to increase visualization, facilitate intubation and reduce the possibility of damage to the incisors.

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This blade for infants and children is gently curved over the distal third and is designed to lift the epiglottis indirectly in the manner of the MacIntosh blade. The blade section permits binocular vision thus allowing better judgment of depth and consequently less risk of trauma. Robertshaw

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Originally produced as an infant blade for use in asphyxia neonatorum , this pattern is available in two sizes extending its usefulness to older children.

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Suitable for premature infants, babies and children up to the age of four. There is sufficient overhang on the open side. It prevents the lips from obscuring vision and the broad, flat lower surface is a help in the small child with an extreme degree of cleft palate.

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Bizzarri – Giuffrida blade :-A modification of the MacIntosh blade with the upper flange removed. This blade is especially well suited for use in patients with a limited mouth opening, prominent incisors , receding mandible short thick neck, or 5. having the larynx in an extreme anterior anatomical position. The absence of the flange greatly reduces the chance of trauma during laryngoscopy .

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The Miller/Port is a modification of the Miller blade that allows the individual to perform laryngoscopy and intubation with less risk of hypoxia. Built into the Miller 0 and Miller 1 blades is a tube that permits delivery of oxygen or other gas mixtures during intubation.

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A modification of the MacIntosh blade which is offset from the handle at an obtuse angle to allow intubation of patients on respirators, in body jackets and other difficult situations .

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This modification of the MacIntosh style blade is designed with the tip angled to further elevate the epiglottis in a patient of short spine.

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The Guedel blade is another original straight blade that has been modified by angling the blade 28° on its base toward the handle. This helps to promote lifting without using the teeth as a fulcrum. The Guedel blade was one of the first blades designed specifically for use with cuffed endotracheal tubes. The distal tip has slightly more angulation than the Flange to assist in the compression of the epiglottis.

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The broad flat shape makes it easier to restrict the neonate and premature infants tongue movement.

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This flexible tip blade with extra bright reflector lamp, English channel to help visualize the epiglottis, stainless steel construction and precise control to elevate the epiglottis.

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Natural lifting action simplifies laryngeal exposure, making intubation possible even in the most difficult cases (receding chin, anterior larynx, protruding teeth, bull neck, facial fractures, decreased jaw mobility, etc.). Built-in leverage prevents prying and reduces possibility of broken teeth. Adapts to all hook-on laryngoscope handles and blades .

PrismView Blade:

PrismView Blade PrismView ™ blades may be used:- a ) when the view of the vocal chords is impaired, especially the most anterior larynx. b ) during nasal intubation and c ) for post operative examination of the larynx. contain an optically polished prism which provides a refraction of 30 without image inversion . To prevent condensation, warm the prism before use by immersing the complete unit in warm water.

Video laryngoscope :

Video laryngoscope The frequent failure of direct laryngoscopy to provide an adequate view for tracheal intubation led to the development of alternative devices such as the lighted stylet , and a number of indirect  fiberoptic viewing laryngoscopes , such as the fiberscope, Bullard scope, Upsher scope,glidescope and the WuScope .. Glidescope video laryngoscope, showing 60-degree angulated blade. The CMOS active pixel sensor(CMOS APS) video camera and light source are located at the point of angulation of the blade.

Video laryngoscope:

Video laryngoscope  video laryngoscopes which employ digital technology such as the CMOS active pixel sensor (CMOS APS) to generate a view of the glottis so that the trachea may be intubated. The  Glidescope  video laryngoscope is one example of such a device. Other examples include the McGrath laryngoscope, Daiken Medical Coopdech C-scope vlp-100, the Storz C-Mac, Pentax AWS, and the Berci DCI laryngoscopes

Glidescope :

Glidescope Anesthesiologist using Glidescope video laryngoscope to  intubate  the trachea of a morbidly obese patient with challenging airway anatomy. It incorporates a high resolution digital camera, connected by a video cable to a high resolution LCD monitor. It can be used for tracheal intubation to provide controlled mechanical ventilation as well as for removal of foreign bodies from the airway.

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The Glidescope owes its superior results to a combination of five key factors: The steep 60-degree angulation of its blade improves the view of the glottis by reducing the requirement for anterior displacement of the tongue. The CMOS APS digital camera is located at the point of angulation of the blade (rather than at the tip). This placement allows the operator to more effectively view the field in front of the camera.

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The video camera is recessed for protection from blood and secretions which might otherwise obstruct the view. The video camera has a relatively wide viewing angle of 50 degrees. The heated lens innovation helps to prevent fogging of the lens, which might otherwise obscure the view.

McGrath video laryngoscope:

McGrath video laryngoscope It is the only laryngoscope to feature a variable length blade for use from children > 5 yrs to large adults. It is designed to provide a clear view of the vocal cords during intubation with little change in laryngoscope technique. A small camera and powerful light source are located at the distal end of the McGRATH video laryngoscope blade. A compact 1.7 inch LCD monitor is directly attached to handle.

Trueview Evo-2 laryngoscope:

Trueview Evo-2 laryngoscope It incorporates an unmagnified optic side port to its special blade which provides a better glottic view due to its enhanced 42 degree anterior refraction and has provision for o 2 insufflation . The Tuview premier TM comes with a 2.5 inch LCD display screen.

Indirect Rigid fiberoptic laryngoscopes:

Indirect Rigid fiberoptic laryngoscopes Bullard laryngoscope WuScope UpsherScope

cormack & Lehane classification:

cormack & Lehane classification grade 3,4 - ↑ risk for difficul t intubation Laryngoscopic view

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Preparation for Rigid Laryngoscopy (trolley) Suction ETT of different sizes Airway Laryngoscope/one more of same size/ pair of batteries 10cc syringe for inflation of cuff Magill forcep Surgical tape/bandage for tying of tube Stylet / Bougie Local spray/local gel (lubricant) Throat pack Emergency medicines Anesthetic machine / Breathing system /vaporizers Monitoring : Pulse Oximeter, Capnograph, ECG, NIBP

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Techniques for intubation ROUTINE RAPID-SEQUENCE UNPREPARED (CRUSH CALL) THREE WAYS :

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Techniques for routine intubation ● Preoxygenation ● Administration of induction agent ● Administration of non depolarizing neuromuscular blocking agent ● Adequate mask ventilation ● Intubation ● Confirm tube in trachea

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Technique for “rapid-sequence” induction and intubation ● Preoxygenation 3 min ● Administration of induction and depolarizing NM blocking agents ● Cricoid pressure ( Sellick maneuver) ● “No” mask ventilation ● Release cricoid pressure after confirmation of tube in trachea

Intubation Technique:

Intubation Technique Position bed height to bring the patient's head to a mid-abdominal height Ventilate with 100 percent oxygen for approximately 3 min Flex the cervical spine and extend the head at the atlanto -occipital joint by putting a pillow of 10cm thickness under head of patient Long axis of the oral cavity, pharynx, and trachea lie almost in a straight line

Intubation Technique:

Intubation Technique Introduce the blade into the right side of the patient's mouth Move the blade posteriorly and toward the midline, sweeping the tongue to the left and keeping it away from the visual path with the flange of the blade Ensure the lower lip is not being pinched by the lower incisors and laryngoscope blade Advance the laryngoscope until the epiglottis is in view

Intubation Technique:

Intubation Technique lift the laryngoscope upward and forward, than tracheal opening will be in front us. Insert the endotracheal tube from the right. Maneuver the endotracheal tube into the larynx, leave after tube cuff crossed the vocal cord

Intubation Technique:

Intubation Technique Inflate the cuff and apply positive pressure ventilation while the assistant auscultates Secure the endotracheal tube in position

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patient's head to a mid-abdominal height & Ventilate with 100 percent oxygen

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Flex the cervical spine and extend the head at the atlanto-occipital joint

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Introduce the blade into the right side of the patient's mouth

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Move the blade posteriorly and toward the midline, sweeping the tongue to the left

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Advance the laryngoscope until the epiglottis is in view. lift the laryngoscope upward and forward , tracheal opening will be in front you

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Insert the endotracheal tube & Secure the ETT in position.

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Sign of Tracheal Intubation ● Chest expansion and decompression (Chest rise & fall) • Auscultate the chest • No gastric distention ● No breath sound over stomach

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● Trauma – Tooth damage – Lip, tongue, mucosal laceration – Dislocated mandible – Retropharyngeal dissection – Cervical spine Complications during Laryngoscopy Complications:

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Complications: During Laryngoscopy ● Physiologic reflexes – HT, Arrthymia – Intracranial pressure raised – Intraocular pressure raised – Bronchospasm

Fibreoptic bronchoscopy:

Fibreoptic bronchoscopy

INTRODUCTION:

INTRODUCTION Bronchoscopy is the general term used to describe the insertion of a visualization instrument ( endoscope ) into the bronchi. The purpose of bronchoscopy are to inspect the airway, remove objects from the airway, collect samples from the airway, and place devices into the airway.

TYPES:

TYPES There are two different types of bronchoscopes : 1.Rigid tube bronchoscope. 2.Flexible fiberoptic bronchoscope

Rigid Tube Bronchoscope:

Rigid Tube Bronchoscope

Scopes:

Scopes Rigid bronchoscope Flexible Fiberoptic Scopes

Flexible Fiberoptic Bronchoscope:

Flexible Fiberoptic Bronchoscope

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Figure 4-4 Flexible fiberoptic bronchoscope. The four channels consist of two that provide a light source, one vision channel, and one open channel that accommodates instruments or allows administration of an anesthetic or oxygen.

Physical properties of the instruments:

Physical properties of the instruments The proximal control section contains: The eyepiece (in fiberoptic bronchoscopes) with diopter adjustment, and The proximal end of the inner channel where suction can be applied, anesthetic or saline instilled, or cytology brushes and biopsy forceps, catheters, etc. The entire length of the insertion cord is covered by a specially treated flexible vinyl tube.

Physical properties of the instruments:

Physical properties of the instruments The external diameter of flexible bronchoscopes range from 0.5 mm (ultrathin) to 6.3 mm. The diameter of the working channel measures from 1.2 to 3.2 mm. The length (usable length) of the insertion cord varies from 200 to 600 mm. The upward or superior deflection ranges from 120° to 180°, whereas the downward or inferior deflection varies from 60° to 130°. The field of view ranges from 70° to 120°.

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Awake fibre-optic intubation Indication: Anticipated difficult intubation , laryngoscopy or mask ventilation Cervical spine instability or cord injury To avoid haemodynamic instability during intubation

Indications :

Indications Three categories Diagnostic Therapeutic Preoperative evaluation of pathology

Diagnostic Indications:

Diagnostic Indications Suspicion of bronchial neoplasm Localized wheeze Atelectasis Persistent pneumonia Positive sputum cytology Assessment of airway After prolonged intubation – to rule out subglottic stenosis , tracheomalacia , tracheo esophageal fistula

Diagnostic Indications :

Diagnostic Indications Tracheobronchial tree examination after smoke injury Double Lumen endotracheal tube insertion To document proper position of DLT For alveolar lavage

Therapeutic Indications:

Therapeutic Indications Removal of aspirated foreign bodies Suctioning of copious secretions Mendelson syndrome - to aspirate particulate matter Instillation of vasoconstrictors Drainage of lung abscess Bronchial stump granulomas

Preparation of the patient :

Preparation of the patient Explanation Premedication Equipment preparation Airway preparation Monitoring

Explanation :

Explanation The reasons for proceeding with an awake fiberoptic intubation The potential complications The type of airway anesthesia that will be provided Possible alternatives to the proposed anesthetic

PRE-MEDICATION:

PRE-MEDICATION Bronchoscopy is an uncomfortable procedure… to decrease anxiety the patient should be premedicated . Tranquilizers such as benzodiazepines is used. Atropine is used to dry the patient’s airway,promotes anesthetic deposition,aids visibility and can reduce procedure time.

PRE-MEDICATION…:

PRE-MEDICATION … 4.Atropine may also decrease vagal responses such as bradycardia and hypotension. 5. Bronchodilator should be administered before the procedure.

EQUIPMENT PREPARATION:

EQUIPMENT PREPARATION All the equipment must be thoroughly checked for function, tight connections, and integrity , this is true for specially small parts and connectors, which can be aspirated if they loosen and disconnect.

AIR WAY PREPARATION:

AIR WAY PREPARATION The goals of airway preparation is to prevent bleeding, decrease cough and gagging and decrease pain. Lignocaine gel is used in the nasopharynx . Lidocaine is delivered by atomizer to the nose, by mouthwash to the oropharynx and by nebulizer and bronchoscope to the lower airways.

Topical anesthesia:

Topical anesthesia Spraying Direct application

Topical anesthesia: direct application :

Topical anesthesia: direct application If nasal intubation is planned, 2 methods of applying local anesthetics are popular: Cotton-tipped swabs soaked in lignocaine and placed superiorly and posteriorly in the nasopharynx . Then left for several minutes to block the branches of the ethmoidal and trigeminal nerves. Coating a nasal airway with viscous lidocaine mixed with a vasoconstrctor .

Nerve blocks :

Nerve blocks Often more difficult to perform, and carry a higher risk of complications than the above mentioned methods. The common complications of nerve blocks are: bleeding, nerve damage, and intra-vascular injection.

Nerve blocks :

Nerve blocks There are 3 blocks used for upper airway anesthesia: 1.glossopharyngeal block – for oropharnyx. 2.superior laryngeal block – larynx above the cords. 3.translaryngeal block – larynx and trachea below the cords.

Glossopharyngeal block:

Glossopharyngeal block There are two way to approach: 1.intra-oral – need enough mouth opening 2.peristyloid – require the ability to distinguish the bony landmarks . For both approaches, careful aspiration for blood must be carried out prior to injection because the glossopharyngeal nerve is closely associated with the internal carotid a. in these locations and even a very small amount of local anesthetic can cause seizures.

Superior laryngeal block:

Superior laryngeal block Performing this block requires some degree of neck extension. Need the ability to identify the greater cornu of the hyoid bone and superior cornu of the thyroid cartilage. The hyoid bone can be easily fractured if excess pressure is applied.

Translaryngeal block:

Translaryngeal block This is more correctly described as a method of topically applying local anesthetic to the trachea and larynx. The coverage of this method is spotty and is most often inadequate for fiberoptic intubation. The method requires access to the ant. neck and some extension of the head, so that the cricothyroid membrane can be identified.

MONITORING:

MONITORING The following should be monitored continuously before, during and / or after bronchoscopy until the patient returns to presedation level of consciousness

MONITORING…:

MONITORING… 1. PATIENT A. Level of consciousness B. Blood pressure, heart rate, rhythm, and changes in the cardiac status. C. Spo2 and Fio2 D. Lavage volumes (delivered and retrieved) E. Medication administered, dosage, route and time of delivery. F. Documentation of site of biopsies/washings and tests requested on each sample G. Periodic postprocedure follow up of patient for 24 to 48 hours

MONITORING…:

MONITORING… 2. TECHNICAL DEVICES Bronchoscope integrity ( fiberoptic or channel damage, passage of leak test) Strict adherence to the recommended procedures for cleaning, disinfection, and sterlization of the devices. Smooth, unhampered operation of biopsy devices( forceps, needles)

CONTRA-INDICATIONS:

CONTRA-INDICATIONS Absolute ( do not perform ) Absence of patient informed consent, unless a medical emergency exists and the patient is not competent. Absence of an experienced bronchoscopist to perform or supervise the procedure. Inability to adequately oxygenate the patient during the procedure

CONTRA-INDIACTIONS…:

CONTRA-INDIACTIONS… PERFORM ONLY IF BENEFIT OUTWEIGHS RISK 1. Coagulopathy or bleeding disorders that cannot be corrected. 2. Severe obstructive air way disease. 3. Unstable hemodynamic status including the arrhythmias 4. Hypoxemia.

CONTRA-INDICATIONS… :

CONTRA-INDICATIONS… Relative ( recognise increased risk ) Lack of Patient co-operation Recent MI or unstable Angina Partial tracheal obstruction Moderate to severe hypoxemia Any hypercapnia Pulmonary HT

CONTRA-INDICATIONS…:

CONTRA-INDICATIONS… 7.Lung abscess 8.Advanced age and malnutrition 9. Respiratory failure

COMPLICATIONS:

COMPLICATIONS Adverse effects of medication used before and during the procedure. Hypoxemia Hypotension Laryngospasm Bradycardia Hypercapnia

COMPLICATIONS… :

COMPLICATIONS… 7. Increased airway resistance 8.Cross contamination of bronchoscopes 9.Mechanical complications like epistaxis, pneumothorax and hemoptysis. 10.Wheezing 11. Death

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Awake fibre-optic intubation’s comlications Poor compliance Coughing Bleeding in airway Excessive secretions Laryngospasm Vomiting Aspiration Airways obstruction

Thank you for your attention !!:

Thank you for your attention !!

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