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LETTERS TO THE EDITOR

Jaw Thrust Maneuver for Endotracheal Intubation Using a Fiberoptic Stylet

Kazuyoshi Aoyama, MD^*, Ichiro Takenaka, MD, Etsuko Nagaoka, MD^*, and Tatsuo Kadoya, MD

Departments of Anesthesia *Moji Rosai Hospital Nippon Steel Yawata Memorial Hospital Kitakyushu, Japan

We read with interest the article by Saruki et al. (1) describing the usefulness of a fiberoptic stylet for endotracheal intubation in patients with difficult airways. The authors used a Macintosh direct laryngoscope for jaw lifting, but the laryngoscope could not lift the epiglottis from the posterior pharyngeal wall (classified as Grade IIIb) in some patients with difficult intubation. In these patients, considerable time to advance the endotracheal tube with a fiberoptic stylet beyond the epiglottis and/or a change of the endotracheal tube to a narrower one was required. In our study (2), we fiberoptically examined the laryngeal aperture during direct laryngoscopy and demonstrated that, in some patients with difficult intubation, the Macintosh laryngoscope could not lift the epiglottis close to the posterior pharyngeal wall sufficiently and could not expand the collapse of the structures around the laryngeal aperture caused by general anesthesia and muscle relaxation (2,3) (Fig. 1A). However, when a jaw thrust maneuver was applied to these patients, the epiglottis was lifted, soft tissues around the laryngeal aperture were expanded, and glottic exposure for fiberscopy was easily achieved (Fig. 1B). With the use of a fiberoptic stylet, therefore, a jaw thrust maneuver applied by grasping the jaw with the operator’s nondominant hand, instead of the laryngoscope, can lift the epiglottis and expand the laryngeal aperture tissues. This procedure can facilitate viewing the glottis though the fiberoptic stylet and passing an endotracheal tube of the standard size through the glottis even when a laryngoscope can not lift the epiglottis sufficiently. A fiberoptic stylet bent into the shape of a hockey stick may be suitable for this technique. We have experienced the same phenomenon during endotracheal intubation under video visual control in some patients with difficult intubation (4).

View larger version (97K): [in this window] [in a new window]   Figure 1. Fiberoptic view during a Macintosh laryngoscopy (A) and during the jaw thrust maneuver (B) in a patient with difficult intubation. The fiberscope was nasally inserted into the laryngopharynx. The laryngoscope (L) can not lift the epiglottis (E), and there is no distance between the epiglottis and the posterior pharyngeal wall. When the fiberscope was somehow advanced beyond the epiglottis, soft tissues around the laryngeal aperture were collapsed. However, during the jaw thrust maneuver, the epiglottis is lifted, the laryngeal aperture expanded, and the glottis becomes clearly visible.

1. Saruki N, Saito S, Sato J, et al. Swift conversion from laryngoscopic to fiberoptic intubation with a new, handy fiberoptic stylet. Anesth Analg 1999;89:526–8.[Free Full Text]
2. Takenaka I, Aoyama K, Kadoya T, et al. Fibreoptic assessment of laryngeal aperture in patients with difficult laryngoscopy. Can J Anesth 1999;46:226–31.[Web of Science][Medline]
3. Murashima K, Fukutome T. Effect of jaw-thrust manoeuvre on the laryngeal inlet. Anaesthesia 1998;53:203–4.[Web of Science][Medline]
4. Aoyama K, Takenaka I, Sata T, Shigematsu A. Use of the fibrescope-video camera system for difficult tracheal intubation. Br J Anaesth 1996;77:662–4.[Abstract/Free Full Text]

Response

Department of Anesthesia Gunma Cancer Center Ota, Japan Department of Anesthesiology & Reanimatology Gunma University School of Medicine Maebashi, Japan

We appreciate the interesting comments of Aoyama et al. about our article (1). We agree that, in the patients who have no distance between the epiglottis and the posterior wall of the pharynx, making space of laryngeal aperture is critical for successful tracheal intubation. That is why, in most of our cases, the anesthetists thought that jaw lifting by using a direct larygoscope was extremely useful for improving viewing and allowing for a swift insertion of the tracheal tube. We considered that a combination of McCoy’s direct laryngoscope and a fiberoptic stylet could be a possible option for extremely difficult cases. However, the jaw thrust maneuver suggested by Aoyama et al. may be another effective technique to facilitate fiberoptic intubation. Further experience seems to be required to establish the most effective use of the fiberoptic stylet in the extremely difficult airway management.

References

1. Saruki N, Saito S, Sato J, et al. Swift conversion from laryngoscopic to fiberoptic intubation with a new, handy fiberoptic stylet. Anesth Analg 1999;89:526–8.

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