Anesthetizing the airway caudal to the vocal cords (in preparation for awake fiberoptic tracheal intubation) may present a clinical challenge because patients may not tolerate a transtracheal procedure or identification of landmarks may prove difficult. Another technique is to insert a bronchoscope through the vocal cords and then spray local anesthetic through the “work port.” However, the latter technique may evoke patient discomfort because the bronchoscope tends to encroach on tracheal mucosa, thereby noxiously stimulating the internal branch of the recurrent laryngeal nerve. Alternatively, we describe a unique method of atraumatically anesthetizing the lower airway using equipment that is readily accessible in most operating rooms.

Via  the suction port of a small adult (3.8 mm OD) bronchoscope (Olympus PortaView® LF-GP Fiberscope, Melville, NY), we insert a 20-gauge nylon closed-end multiorifice epidural catheter (model 11771-01; Portex, Keene, NH) until the tip of the catheter begins to emerge from the distal tip of the bronchoscope (fig. 1). A local anesthesia–containing syringe is affixed to the bronchoscope (fig. 1), thereby freeing both hands for bronchoscope operation. After oropharyngeal topical application of local anesthetic, the bronchoscope is inserted until the tip lies immediately superior to the vocal cords. Thereafter, the epidural catheter is advanced (fig. 2) into the trachea under direct visualization, and local anesthesia is sprayed during catheter advancement. When anesthesia has been achieved, the bronchoscope is inserted into the trachea, and the endotracheal tube is advanced.

* Mayo Clinic and Mayo Foundation, Rochester, Minnesota.