Confirmation of tracheal tube placement with a flexible bronchoscope when the capnograph trace is absent due to bronchospasm

Detection of sustained, exhaled carbon dioxide by waveform capnography is an essential component of tracheal intubation in current practice. However, this may be impossible in rare clinical situations. International guidelines include flexible bronchoscopy as an alternative method of confirming tracheal intubation when capnography is inconclusive and tube removal is considered dangerous. We present the case of a patient with severe bronchospasm who aspirated gastric contents at induction of anaesthesia for ventilatory support for respiratory failure. Following apparent tracheal intubation, ventilation appeared impossible and no capnography trace could be obtained. Tracheal intubation was confirmed using flexible bronchoscopy, and the patient subsequently recovered following a period of extracorporeal membrane oxygenation. This case illustrates the value of flexible bronchoscopy in the unusual situation when ventilation is so compromised that capnography is unobtainable.