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Prehospital emergency endotracheal intubation using the Bonfils intubation fiberscope


Difficult intubating conditions are prevalent in 7–10% of patients who require out-of-hospital emergency endotracheal intubation. Airway anatomy can further be deteriorated through trauma, bleeding, and the use of cervical spine (CS) immobilization collars. We evaluated the feasibility of the Bonfils intubation fiberscope for prehospital emergency endotracheal intubation.

Materials and methods

The Bonfils intubation fiberscope (Karl Storz GmbH, Tuttlingen, Germany) is a reusable, rigid, straight fiberoptic device with a 40° curved tip, 40 cm long and 5 mm in diameter. A flexible eyepiece is mounted on the handle of the scope. The fiberscope has a connector that fits onto the 15-mm tracheal tube adapter and thereby allows oxygen insufflation. A cold light source or a small battery handle (powered by two 1.5 V alkaline batteries) can be attached to the stylet handle. The tip of the Bonfils intubation fiberscope is positioned just proximal to the tip of the attached endotracheal tube, thereby preventing the lens from being soiled with blood or secretions. Having adopted the Bonfils technique in our institution, we felt that because of its battery-powered light source the Bonfils intubation fiberscope could also be used in prehospital settings, independent of a 110/220 V cold light source. After appropriate inhospital training with the Bonfils intubation in anesthetized patients, our hospital's mobile emergency unit staffed with an emergency physician was equipped with a battery-powered Bonfils intubation fiberscope.


During 123 missions, 15 adult patients underwent pre-hospital endotracheal intubation (cardiac arrest n = 9, multiple injuries n = 4, drug poisoning n = 1, pulmonary edema n = 1) with the Bonfils intubation fiberscope, the use of which was either planned (n = 13) or unplanned (n = 2). All intubations were successful in the first attempt, even in two cardiac arrest victims who had an unexpected difficult airway (Cormack&Lehane grade IV under direct laryngoscopy). In those patients with multiple injuries the cervical immobilization collar did not need to be unfastened or removed for endotracheal intubation. Sufficient retropharyngeal space – which is mandatory for sufficient use of the Bonfils – was created by a digital jaw thrust maneuver in the first three patients. Using a standard Mackintosh laryngoscope blade significantly enhanced ease of insertion of the Bonfils fiberscope and visualization of the glottic aperture, thereby decreasing the procedure time from 35–40 seconds to 20–25 seconds.


Despite this first promising series of in-the-field use, physicians and paramedics should familiarize themselves with the Bonfils device under optimal clinical conditions before using it under emergency or prehospital conditions. In our experience, the learning curve with the Bonfils device is steep, and 10 intubations supervised by an instructor usually prove effective for achieving sufficient skills to use the Bonfils on one's own and under less optimal conditions. In summary, we believe that the Bonfils fiberscope will prove its value as an additional airway management device in both, emergency and prehospital settings.


The Bonfils intubation fiberscope was generously provided by Karl Storz GmbH, Tuttlingen, Germany.

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Byhahn, C., Breitkreutz, R., Viehmeyer, S. et al. Prehospital emergency endotracheal intubation using the Bonfils intubation fiberscope. Crit Care 11 (Suppl 2), P211 (2007).

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