Authors: Heidegger T et al.
Anesthesiology Open 1(1): e0011, January 2026. 10.1097/ao9.0000000000000011
Summary
Flexible bronchoscope–guided tracheal intubation remains the gold standard for managing anticipated difficult airways. Despite its importance and inclusion in major airway management guidelines such as those from the American Society of Anesthesiologists, the technique is underused in clinical practice. Surveys consistently show that while most anesthesiologists believe bronchoscope-guided intubation is an essential skill, more than 30% report insufficient proficiency. This creates a significant safety gap. Two key reasons for underutilization are lack of provider expertise and concern about patient tolerance, especially during awake intubation.
Traditional bronchoscope-guided intubation is a two-step procedure. First, the bronchoscope is inserted into the trachea. Second, an endotracheal tube that has been preloaded over the scope is advanced into the airway. These steps often require different levels of sedation and topical anesthesia, which can create a mismatch in patient comfort and airway conditions. Difficulties during tube advancement—including resistance at the arytenoids, bleeding during nasal approaches, coughing, or patient discomfort—can lead to procedural failure. Major airway safety analyses such as the Fourth National Audit Project (NAP4) and malpractice closed-claims studies have identified these challenges as contributors to adverse outcomes.
The authors propose a conceptual redesign of the procedure into a one-step bronchoscope-guided intubation technique using a re-engineered expandable endotracheal tube. In this proposed approach, the tube initially fits tightly around the bronchoscope like a “second skin.” During insertion, the outer diameter of the combined device is only slightly larger than the bronchoscope itself, improving maneuverability and patient tolerance. Once the bronchoscope tip is positioned appropriately in the trachea, the tube expands into its final shape, forming a standard ventilation lumen without requiring the traditional step of advancing the tube over the scope.
By eliminating the second step of tube advancement, this design could remove many common problems associated with bronchoscope-guided intubation. These include tube hang-up on airway structures, airway trauma, bleeding, coughing, and procedural delays. It may also simplify sedation management during awake intubation, since the tube expansion occurs only after the bronchoscope is already correctly positioned.
For the concept to work clinically, the expandable tube must meet several engineering requirements. It must attach tightly to the bronchoscope during insertion without compromising flexibility. Once deployed, the bronchoscope must detach easily from the expanded tube. The final tube must also maintain adequate structural stability within the airway and provide a sufficiently large lumen for ventilation. Importantly, if expansion fails due to a mechanical problem, the bronchoscope can still function as in conventional techniques.
The authors outline several potential engineering solutions for the expandable tube. These include a self-expanding stent mechanism, inflatable ring structures, spiral inflatable designs that resist kinking, inflatable multi-lumen tubes with structural bridges for stability, spring-like self-expanding structures, and compressed foam systems that expand once deployed. Each concept aims to transform the bronchoscope-mounted device into a full-sized airway tube after correct tracheal placement.
Although this technology remains theoretical and requires prototype development and testing, the authors argue that simplifying bronchoscope-guided intubation could increase clinician willingness to use the technique when indicated. By lowering the technical barrier and reducing patient discomfort, this innovation could improve patient safety in anticipated difficult airway management.
Key Points
• Flexible bronchoscope-guided intubation remains the gold standard for anticipated difficult airways but is underused due to technical complexity and provider inexperience.
• Traditional bronchoscope intubation requires a two-step process: bronchoscope placement followed by advancement of the endotracheal tube.
• Many failures occur during the second step because of airway resistance, sedation mismatch, or patient discomfort.
• The authors propose a one-step system using an expandable tube that fits tightly around the bronchoscope during insertion and expands once positioned in the trachea.
• Potential designs include self-expanding stents, inflatable ring systems, spiral inflatable tubes, multi-lumen inflatable structures, spring mechanisms, and expandable foam.
• If successfully developed, the technique could simplify awake intubation and potentially improve patient safety in difficult airway management.
We thank Anesthesiology Open for allowing us to summarize this article.