Jaw Thrust Maneuver for Endotracheal Intubation Using a Fiberoptic Stylet

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).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.Kazuyoshi Aoyama MD* Ichiro Takenaka MD† Etsuko Nagaoka MD* Tatsuo Kadoya MD†