C-MAC + Bonfils Scope for Extremely Difficult Airways

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The combination of videolaryngoscopy (VL) and Bonfils rigid intubation endoscope (BIE) was an excellent way to safely intubate patients with extremely difficult airways.

Why does this matter?
Having a difficult airway plan is important, potentially life saving.  Most start with a VL, have a bougie handy, and will pop in a LMA in a pinch, reserving emergency cricothyrotomy as a final option.  There are a few case reports using a combination of VL with endoscopy, but it has not been rigorously studied.  I tinkered around with a Bonfils rigid intubating scope (link is a video) on a manikin once at ACEP, and it was fantastic.  But it is totally different than any other kind of intubation and not that intuitive, so practice a lot on a manikin or cadaver before using it on a patient.

Lights, cameras, intubate...
This was a non-randomized study of 38 patients with known difficult airway or at least 1 predictor of difficult airway and Cormack & Lehane grade III or IV view on VL with a C-MAC.  In other words, these were very difficult airways.  C&L grade was scored 3 times and a photo taken at each stage: DL, VL, and VL+BIE. Two anesthesiologists blinded to the method used for the photo viewed the glottic images and assessed C&L grade at each stage.  Overall, C&L grade improved with the combined VL+BIE approach in 33/38 (87%). This is a great way to approach patients with known or highly suspected difficult airway - assuming you have a Bonfils endoscope, which isn't cheap.

Source
Macintosh Blade Videolaryngoscopy Combined With Rigid Bonfils Intubation Endoscope Offers a Suitable Alternative for Patients With Difficult Airways.  Anesth Analg. 2017 Dec 15. doi: 10.1213/ANE.0000000000002739. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.  

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