Anaesthesia, 2004, 59, pages 1207–1209

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APPARATUS
Tracheal intubation using the Bonfils intubation fibrescope
after failed direct laryngoscopy*
B. Bein,1 M. Yan,1,6 P. H. Tonner,2 J. Scholz,4 M. Steinfath2 and V. Dörges3
1 Staff Member, 2 Professor, 3 Associate Professor, 4 Professor and Chair, Department of Anaesthesiology and Intensive
Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105 Kiel, Germany
6 Current address: Department of Anaesthesiology, no. 2 Affiliated Hospital, Medical College, Zhejiang University,
China

Summary
Failed tracheal intubation due to a difficult airway is an important cause of anaesthetic morbidity
and mortality. This study was undertaken to evaluate the effectiveness of the Bonfils intubation
fibrescope for tracheal intubation after failed direct laryngoscopy. Twenty-five patients undergoing
coronary artery bypass grafting were enrolled in the study after two attempts at conventional
laryngoscopy by a board certified anaesthetist had failed. Intubation with the Bonfils fibrescope was
successful on the first attempt in 22 patients (88%) and on the first or second attempt in 24 patients
(96%); in one patient intubation was impossible. Median (IQR [range]) time to intubation
using the Bonfils intubation fibrescope was 47.5 (30–80 [20–200]) s. Tracheal intubation using
the Bonfils intubation fibrescope appears to be a simple and effective technique for the manage-
ment of a difficult intubation.

Keywords Intubation, intratracheal; laryngoscopy.

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Correspondence to: Dr B. Bein
E-mail: bein@anaesthesie.uni-kiel.de
*Presented in part at the American Society of Anaesthesiologists’
Annual Meeting, Las Vegas: October 2004.
Accepted: 13 August 2004

Failed tracheal intubation due to an unexpected difficult to be suitable for tracheal intubation in patients with
airway is an important cause of anaesthetic morbidity and normal as well as with predicted difficult airways [5, 6].
mortality [1]. After failed conventional direct laryngo- The aim of the current study was to assess the Bonfils
scopy, possible alternative devices include rigid and intubation fibrescope as an intubating tool during the
flexible fibrescopes, and modified laryngoscope blades. management of patients with proven difficult airways, i.e.
Although these may facilitate management of unexpected after failed direct laryngoscopy.
difficult intubation, several limitations apply to their use
in clinical practice, e.g. a long preparation time, costly
Methods
equipment and the need for extensive training [2, 3].
The Bonfils intubation fibrescope (Karl Storz GmbH, After Local Research Ethics Committee approval, 25
Tuttlingen, Germany), a rigid fibrescope with a curved patients of ASA physical status 3, scheduled for elective
tip akin to a modified and enhanced type of lighted stylet, coronary artery bypass grafting between January 2003 and
was introduced into clinical practice in the 1980s [4], but June 2004, were selected. We did not seek informed
there are few data available about this device [5–7]. Only consent since airway management strictly followed the
a short time is required for its preparation and therefore it standard operating procedures of our institution which, in
can be used quickly in an emergency situation. In two turn, were based on the ASA difficult airway algorithm
recent studies the Bonfils intubation fibrescope was found [8], but patients gave written consent to data analysis

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B. Bein et al. Æ Bonfils intubation fibrescope Anaesthesia, 2004, 59, pages 1207–1209
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and publication. Patients with a history of difficult or Table 1 Characteristics of 25 patients in whom direct laryngo-
impossible mask ventilation, or in whom induction of scopy failed and the Bonfils intubation fibrescope was used.
Values are mean (SD) or number (proportion).
general anaesthesia was precluded for other reasons, were
excluded from the study.
Age; years 67 (10)
After pre-oxygenation via a facemask for 3 min, Height; cm 173 (7)
anaesthesia was induced with 2 mg.kg)1 propofol and Weight; kg 81 (16)
0.3 lg.kg)1 sufentanil. If ventilation via the facemask Cormack–Lehane grade [9]
I 0
was successful, neuromuscular blockade was achieved II 0
with 0.6 mg.kg)1 rocuronium and neuromuscular mon- III 6 (24%)
itoring was started; anaesthesia was subsequently main- IV 19 (76%)

tained with propofol 6–8 mg.kg)1.h)1 and sufentanil

0.15 lg.kg)1.h)1. After adequate neuromuscular block- Adverse events during intubation were recorded and
ade was confirmed with train-of-four peripheral nerve defined as aspiration ⁄ regurgitation, hypoxaemia (SpO2 <
stimulation, the patient’s head was put in the neutral 90%), bronchospasm ⁄ airway obstruction, and dental
position. Direct laryngoscopy was then performed using a trauma.
Macintosh blade size 3 or 4, as appropriate, and the
laryngoscopic view graded according to Cormack &
Results
Lehane [9]. If tracheal intubation failed with the first
attempt, the patient’s head was readjusted in the ‘sniffing’ Patient’ characteristics are displayed in Table 1. During
position and the tracheal tube equipped with a bougie. A the study period, 1430 patients were anaesthetised in the
BURP manoeuvre (backward, upward and rightward cardiac surgery theatres. Of these, the tracheas of
pressure) was used if appropriate [10]. After two failed 25 patients could not be intubated by conventional direct
attempts at tracheal intubation by a board certified laryngoscopy; intubation time using the Bonfils intuba-
anaesthetist, the Bonfils intubation fibrescope was used tion fibrescope in these patients ranged from 20 to 200 s
as an airway adjunct. (median (IQR) 47.5 (30–80) s). Intubation with the
The Bonfils intubation fibrescope, first described by Bonfils intubation fibrescope failed on the first attempt in
P. Bonfils in 1983, has been described in detail two patients, both with Cormack–Lehane laryngoscopy
elsewhere [4–6]. Briefly, it is a reusable rigid straight grade 4. Intubation was successful in both of these patients
fibrescope with a curved tip (40) and a movable on the second attempt, in one of them using the Bonfils
eyepiece mounted on the handle of the scope. Using intubation fibrescope alone (total intubation time 90 s)
the Bonfils intubation fibrescope, the patient’s mouth is and in the other with the help of conventional laryngo-
opened and the scope inserted from the right side along scopy performed by a second anaesthetist (total intubation
the molars. With the insertion of the device, either a time 200 s). In one patient, gross mucous secretion in the
jaw thrust manoeuvre or laryngoscopy with a conven- mouth and pharynx prevented a view of the glottic
tional Macintosh blade is performed in order to enlarge aperture even after two attempts with the Bonfils
the retropharyngeal space. Following this, guided by intubation fibrescope, despite applying suction after
the right hand, the anaesthetist advances the Bonfils insertion of a conventional blade; this patient’s trachea
intubation fibrescope up to the glottic aperture and was nasally intubated with a flexible bronchoscope.
then inserts the tracheal tube into the trachea under No adverse events were observed.
direct vision. An 8.0-mm tracheal tube was used for
male patients and a 7.0-mm tube for females. The
Discussion
Bonfils intubation fibrescope was used by two anaes-
thetists (B.B. and V.D.) experienced in its use (> 50 In this study the Bonfils intubation fibrescope had a high
intubations each). Since particular attention must be success rate after failed direct laryngoscopy: tracheal
paid to avoiding arterial oxygen desaturation in these intubation was completed successfully in all but one
patients, intermittent mask ventilation was allowed. patient. Intubation time was clinically acceptable despite a
Time to intubation with the Bonfils intubation fibre- Cormack–Lehane laryngoscopic view of grade 4 in 76%
scope was therefore measured from first touching the of the patients.
device after failed laryngoscopy until the first expiratory New airway devices are introduced with ever-increas-
tidal volume exceeding 200 ml was recorded. The time ing frequency; anaesthetists are unlikely to have the
required for intermittent mask ventilation between the opportunity to use them all and, more importantly, do
individual attempts with the Bonfils intubation fibre- not have the time to become proficient in all of them.
scope was subtracted from the total time. Therefore, it is a reasonable approach to develop expertise

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Anaesthesia, 2004, 59, pages 1207–1209 B. Bein et al. Æ Bonfils intubation fibrescope
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in one or two tried and tested and universally applicable
techniques. Since the success of emergency airway
management is influenced by the degree of training and
familiarity with the device used, an airway adjunct ideally
should be suitable for use in daily anaesthetic practice
without increasing postanaesthesia airway morbidity. In
two recent studies, the Bonfils intubation fibrescope has
proven its feasibility in this respect in patients with normal
as well as predicted difficult airways [5, 6]. In contrast to
the latter study, patients in the present investigation
presented with a difficult or impossible laryngoscopy.
In the past decade, fibreoptic intubation has evolved as a
‘gold standard’ for the management of this patient
population [1]. However, the need for extensive training
and costly equipment are disadvantages. In cases of an
unexpected difficult airway, time-consuming preparation
of the equipment is the most important issue. Recently, a
modified laryngeal mask airway, the intubating laryngeal
mask airway, has been advocated as a tool for intubating
the tracheas of patients with a difficult airway [11, 12] as
an alternative approach.
Compared with the flexible fibrescope, the Bonfils
intubation fibrescope has several advantages and dis-
advantages. The Bonfils intubation fibrescope equipment
is not as extensive or expensive, and the preparation time
is shorter. On the other hand, in contrast to a flexible
fibrescope, the Bonfils intubation fibrescope cannot be
used nasally. In addition, it provides no suctioning
channel; therefore, large amounts of mucous secretions
or blood in the airway may prevent successful use if blind
suctioning is impossible or unsuccessful. Indeed, our only
failure with the Bonfils intubation fibrescope was caused
by inability to remove heavy mucous secretions in the
pharynx. However, the small suctioning channel provi-
ded in the flexible fibrescope may also be insufficient for
draining larger amounts of fluids in the airway. To date,
the Bonfils intubation fibrescope has not been compared
with the flexible fibrescope in a systematic fashion.
Comparing the Bonfils intubation fibrescope with the
intubating laryngeal mask airway in patients with a
predicted difficult airway, we previously found a com-
parable success rate but a significantly shorter time to
intubation in the Bonfils group (median (range) 40 (23–
77) s vs. 76 (45–155) s) and a decreased postanaesthesia
airway morbidity [5]. Since the use of the intubating
laryngeal mask airway cannot be recommended in
patients with previous cervical radiotherapy [11], the
small diameter of the Bonfils intubation fibrescope
(determined just by the outside diameter of the attached
tracheal tube), requiring only minimal mouth opening,
may be advantageous in this subset of patients [7].
The main advantages of the Bonfils fibrescope are
reasonable costs (approximately £2350), simple cleaning
and disinfecting routines, and the simplicity of the
intubation technique, with a steep learning curve after a
limited time of training [6]. Furthermore, the small and
easily transportable equipment may be especially useful
in emergency situations and in cases of unexpected
difficult airway outside the operation room, e.g. on the
ward.
Acknowledgements
The Bonfils intubation fibrescope was supplied by Karl
Storz GmbH, Tuttlingen, Germany. We are indebted to
Volkmar Haensel-Bringmann, RN, for his enthusiastic
assistance.
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