In the very crowded area of airway management

for anesthesia and critical care medicine several

authors reported interesting comparison among

the different techniques to perform a rapid and

safety intubation for routinely approach or unexpected difficulty.

Recently Takashi Asai focuses the role of  techniques vision based

 in the solution of problems with tracheal intubation.

The essential message coming from Takashi Asai

signify that the entire intubation procedure

requires visualization of the vocal cords and

that the endotracheal tube should be introduced

under visual control.

Under general anesthesia, the entire tracheal intubation

procedure should be carried out under visual control to limit the risks.

Recently, many devices have been developed that

allow laryngeal visualization.

But these are limited to the first stage of the procedure,

i.e., visualization of the glottis.

The second phase, insertion of the

endotracheal tube, is sometimes performed blind,

which carries a risk of trauma and bleeding.


The only instrument that provides full visualization

throughout intubation is the flexible bronchoscope.

In our Oncologic Institute, we often encounter patients

who have cancers located in the head and neck regions,

necessitating the use of a flexible bronchoscope.

Under conditions of anesthesia with muscle relaxation,

the use of a flexible bronchoscope can be difficult.

Thus, we have developed an intubation technique

that uses a flexible bronchoscope in combination

with the MacIntosh laryngoscope under anesthesia

with muscle relaxation for unexpected difficult intubations .
The MacIntosh laryngoscope acts as a lever, allowing

for normal maneuvering of the bronchoscope under anesthesia.

This technique has allowed successful intubation

even in cases with laryngeal visualization of Cormack grade 4

The procedure was performed successfully by an

experienced anesthesiologists in 200 hundred

surgical patients.

The ethics committee approved the standardization

and the method for training the young anesthesiologists

in the use of the combined intubation technique.

We started a cooperative project with the Medical School

of Anesthesiology in Catania for training

the fellows under the tutor guidance.

The results obtained from a comprehensive 314

surgical procedures involving the neck, abdomen, breast,

and spinal cord are encouraging .

Using an algorithm that uses the combined technique

in cases of Cormack-Lehane grade 3 and up ,

no attempts were made at blind intubation.

Instead, the combined technique was used

successfully in 51 cases out of 51.

Our technique should be performed by other teams

to confirm its efficacy. Owing to its simplicity

and low cost, this combined method could simplify

intubation under general anesthesia with muscle relaxation,

and it is our experience that it can be learned

quickly by novice operators. In our practice,

it has taken an average of ten procedures for

a novice to reach proficiency.



1) Asai, T: Videolaryngoscopes: do they truly have roles in difficult airways?
Anesthesiology 2012 Mar; 116(3): 515–7