Fiberoptic Tracheal Intubation
Objectives: We will (be able to):
1. Explain how to properly play (deftly drive) the flexible fiberscope.
2. Explain selected technics for nasal and oral flexible fiberoptic intubation (FFI).
3. Explain slelcted technics to provide local anesthesia for awake/sedated intubation.
4. Be inspired to drive that scope!

FFI is a most powerful technic for efficient easy intubation of "difficult laryngoscopy" patients otherwise impossible to intubate.
Best used as a first line technic whenever some difficulty with DL is anticipated; not a backup or reserve technic to be used only after conventional DL has failed! Opportunities for FFI are then frequent enough to develop and maintain skill.

I. Playing the Flexible Fiberscope
Tune first
Load the endotracheal tube onto the fiberscope. The adapter is best left on the tube and perhaps taped to the proximal portion of the scope to keep it out of the way until needed.
Attach and turn on a good light source.
Attach camera (and color balance the camera) if one is available. This allows for most comfortable posture and ease of visualization and demonstration during the FFI.
Focus camera on finger prints or some fine print.
Assume proper playing postion
Dr. Ovassapian in playing position Stand tall, relaxed.
Left hand up with digits 3,4 and 5 holding proximal scope so that left index finger tip rests near suction port on side opposite operator and left thumb tip is flexed onto scope flexion control on same side as operator.
Right hand down on or near patient's face with right fifth digit perhaps resting on face (watch out for right eye) and intubating, distal end of scope stabilized by right thumb, index and middle fingers like holding a pencil.
The scope should always be held approximately straight between the hands. In the photo, note satisfactory positions of operator and assistant (no camera available). Note operator's left hand on control section, right hand on insertion end and scope essentially straight. Assistant lifts mandible.
Play it! Drive that scope!
Steady right hand on patient helps fine control and provides stabilization of scope at airway entry point.
Left hand gradually lowers toward right as scope is advanced through right hand guiding fingers.
Watch where you are going! (This should not be a blind technic!)
Observe triangular marker at 12 o'clock position (represents flexion plane).
You can move the scope tip to any location you see with only three (with practice, coordinated) motions:
flexion of scope tip along the 6 to 12 o'clock flexion plane;
rotation of scope (of entire scope: avoid twisting and damaging fibers);
advance (and withdrawal) of scope.
Your desired destination point(s) should be (successively) brought to and maintained in the center of the field of vision by 1) rotating (entire) scope to bring point into the flexion plane, then 2) flexing scope tip to bring point to center of view. Slowly advance a little toward the destination point once that point is in the center of the field of view. Continue to maintain destination point(s) in center of field of view by appropriate rotation, flexion, then slow advance. Rotate, flex, advance, rotate, flex, advance...
Move slowly for fastest results!

II. FFI Technics
Nasal Flexible Fiberoptic Intubation (FFI)
The nasal techic is preferred by most experienced operators. The patient's natural landmarks aid proper alignment of scope. The larynx is approached from farther away so glottis is more easily reached with relatively slight flexion of scope. Even awake patient cannot bite scope (or operator's fingers)!
Decide on a general approach:
1. GA, muscle relaxants, controlled ventilation
2. GA, spontaneous or assisted ventilation
3. Awake, sedated with or without local/topical anesthesia
Communicate plan to patient and OR team.
Consider antisialogogue and/or topical anesthesia (e.g., 4-5% lidocaine aerosol) preoperatively.
Assemble and check equipment.
oral and nasal airways, tongue blades
appropriate ETT's, syringes
lubricant (5% lidocaine ointment or 2% lidocaine jelly, surgilube)
fiberoptic scope -- attach and check suction/oxygen, camera, white balance, focus
(video equipment very helpful for learning, teaching)
light source attached, turned on
prepare ETT (e.g., cut nasal RAE) and load securely onto scope
lubricate scope (avoid fiber tip) and tube
Adjuvant drugs
glycopyrrolate (prior to lidocaine aerosol for best effect)
phenylephrine or oxymetazolone
local anesthetics: lidocaine, benzocaine
Assistant very helpful
Induce GA as planned
Confirm that ventilation may be assisted and then controlled by bag and mask (or via nasal airway) prior to any planned muscle relaxant administration.
Remove pillow and instruct assistant to lift patient's chin, extending head (if not contraindicated), thus tending to lift epilottic tip up and away from posterior pharyngeal wall.
Assume playing position: contol section of scope in left hand with thumb on flexion control, index finger near suction; right hand supporting distal insertion end of scope with fifth finger perhaps stabilized on zygoma (watch, tape eyes).
Gently lift the ala naris (right usually easier) with scope and visually locate the inferior turbinate (about 1 cm beyond naris along lateral border of floor of nose, it "leads the way" by "pointing" right to the choana)
Gently, slowly advance scope along and parallel to the inferior turbinate to the choana. Stay in center of lumen. Avoid scraping mucosa.
Fiberoptic View of Base of Tongue and Epiglottis Slowly flex scope under choana into nasopharynx, advance past uvula into oropharynx and under base of tongue. Observe epiglottis, aryepiglottic folds, or other part(s) of glottis. Rotate and flex to bring epiglottis (and glottis) into center of field of vision. Slowly advance scope tip under epiglottis (or around one side if necessary).
Fiberoptic View of Glottis Approach the anterior commisure (maintain in center of view).
From just above the anterior commisure, flex the scope slightly posteriorly and advance through cords into trachea. Visualize tracheal rings. Advance to carina. Throughout, stay in center of lumen. Steer around any secretions or blood, and avoid contact with mucosal walls and tissues.
Stabilize scope with left hand (lock elbow joint).
With right hand, advance well-lubricated ETT along scope gently through nose and to the larynx and into the trachea. If some resistance is felt as the tube meets the glottic rim (about 50% of the time), withdraw tube along scope 1-3 cm, rotate scope 90 degrees, gently readvance and repeat until ETT advances easily along scope into trachea.
Confirm tip of ETT in trachea above carina.
Hold ETT and remove scope.
Secure ETT.
Clean the scope suction channel by suctioning several hundred ml of water through scope.
Note: during FFI, oxygen or lidocaine may be administered through the suction channel prn.

Nasal FFI - Modifications
Relatively small nasal airway inserted gently, atraumatically after oxymetazoline administration into the smaller nasal passage may be used to
  • Deliver O2
  • Assist ventilation
  • Monitor ETCO2
  • Deliver an inhalation agent
  • Deliver topical local anesthetic (e.g., lidocaine)
  • Provide alternate channel for suctioning
  • Provide "guide" that may be followed by fiberscope through blood and/or secretions (scope advanced along side and parallel to nasal airway through naso-oropharynx)
Oral FFI - Modifications
Equipment: oral airways, guides, bite block, tongue blades, maybe even a perforated nipple for infant endoscopy:
Nipple Fiberscope Guide
Beware teeth!
Oral guide may be helpful but if poorly aligned may make the intubation difficult or impossible.
NEW tool that if properly positioned almost always greatly facilitates oral FFI: the LMA!
Fiberoptic Intubation via LMA
Epiglottis/glottis seen immediately beyond the LMA tube. #6 ETT fits through #4 or 5 LMA (see table). Check fit before using. This technic requires only a few centimeters of scope-driving talent. A recommended option for ventilation and intubation of the difficult airway!
See: LMA-assisted fiberotptic intubation

Also see fiberoptic-assisted retrograde technic,
and local/topical anesthesia of the airway.

IV. Inspirational
FFI is much easier than playing a violin, flying a plane or even driving a car. Following competent instruction, it takes junior anesthesiology residents only about 10 to 20 fiberoptic intubations to reduce average time to less than about 1 minute! Drive that scope!

Greg Gordon MD
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