Fiberoptic Orotracheal Intubation in the Left Semilateral Position

To the Editor: Endotracheal intubation in the left lateral position is still recommended by some authorities (1,2). The left lateral position prevents the laryngeal structure from collapsing, and this position is recommended in adult basic life support (3). We assessed the usefulness of semilateral positioning for visualizing the larynx during fiberoptic orotracheal intubation. After obtaining approval from the Division Ethics Committee of the IRB and written informed consent, 50 scheduled surgical patients were studied. After inducting anesthesia and confirming adequate mask ventilation, we inserted the fiberoptic bronchoscope (FOB) into the patient’s larynx in the common supine position without assistance, in the supine position with assistance that consisted of holding the lower jaw upward, and in the left semilateral position using a soft pillow under the right side of the back and rotating the head of the patient naturally to the left (Fig. 1). The degree of visualization of the laryngeal structure was evaluated using the classification of Aoyama et al. (4). In the supine position, visualizing the glottis through the FOB was impossible in 44 patients (88%) (Table 1), whereas visualizing the glottis was easy in 41 patients (82%) in the semilateral position.Figure 1: A view of the left semilateral position immediately before intubation. The patient’s neck naturally turns to the left and the fiberoptic bronchoscope is inserted through the mouth. The patient was Yushi U. Adachi, MD himself during induction of anesthesia for neurinoma surgery.Table 1: Visualization for Laryngeal Structure in Three PositionsDimitriou and Voyagis (5) reported a light-guided intubating technique with patients lying in the lateral position. We used only “semilateral” positioning in each patient; however, we never anticipated the quality of the view that could be acquired in this position. Although the FOB is a powerful tool for difficult intubation, the most important factor is obtaining an optimal view (6). Left semilateral positioning using only a soft pillow produced a sufficiently good view of laryngeal structure using a FOB without an assistant (7) or special devices (4). Yushi U. Adachi, MD Maiko Satomoto, MD Hideyuki Higuchi, MD, PhD