An algorithm for easy intubation. Combined use of the MacIntosh laryngoscope and flexible bronchoscope in unexpected difficult intubation

Background. We evaluated the efficacy, safety, and learning curve for the combined use of the MacIntosh laryngoscope and flexible bronchoscope under general anesthesia with muscle relaxation. We also evaluated the effectiveness of an algorithm for injury-free intubation. Methods. For standardization and training, from 2010-2011 we enrolled 314 patients >18 years of age who were undergoing non-emergency oncologic, thyroid, urological, otolaryngological, or spinal column surgery. A total of 2143 intubations were performed based on an algorithm that was able to predict direct passage from traditional methods to a combined technique and that prevented any predicted difficult intubation after laryngoscopy. Results. All patients were treated successfully with the combined technique. In 253 patients (80.5%), intubation was accomplished within 1 minute; in 53 patients (16.8%), within 3 minutes; and in 8 patients (2.5%), longer than 3 minutes. SaO2 was maintained at 95-100%. On average, 10 procedures were needed for novice operators to attain proficiency in the technique. In the algorithm group, 2092 procedures were performed using the traditional technique and 51 (Cormak-Lehane III-IV Laringoscopy) using the combined technique without injury or bleeding. Conclusions. We obtained optimal results with the combined method, which was quickly learned by others. The algorithm described herein allows for safe intubation without injuries. Because of its simplicity and low cost, this combined approach could become a common solution for unexpected difficult intubations under general anesthesia with muscle relaxation.