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Fiberoptic Endotracheal Intubation Procedure

Indications

  • Anticipated difficult intubation (upper airway abnormality)
  • Endotracheal intubation when neck extension is not desirable (cervical spine injury, rheumatoid arthritis)

Contraindications

  • Inability to oxygenate
  • Major bleeding

Technique

  1. Oral route preferable
  2. Topical anesthesia with 2% lidocaine on a base of the tongue, hypopharynx and vocal cords (aerosolized 10% lidocaine may also be used)
  3. Sedation with midazolam (adult dose 1 to 2.5 mg IV) and fentanyl (adult dose 25-100 mcg IV)
  4. "Jaw thrust" maneuver improve visualization
  5. Apply oral airway or "bite block" to protect the equipment. Apply 100% oxygen via face mask (oxygen may also be delivered via bronchoscope channel)
  6. After the bronchoscope is lubricated and loaded with an endotracheal tube it is introduced strictly in the midline following the base of the tongue, pass the uvula, behind the epiglottis and between the vocal cords. (see video on the left below).
  7. Additional topical lidocaine is applied as necessary.
  8. Once the main carina is visualized endotracheal tube is introduced by rotating movement over the bronchoscope. Proper position (3-5 cm above the carina) is evaluated and the tube secured. (see video on right below)
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Advantages

  • Excellent airway visualization
  • Minimal hemodynamic stress

Disadvantages

  • Costs associated with the need for special equipment and skill

Complications

  • Oxygen desaturation
  • Bronchospasm (inadequate local anesthesia)

Quiz Questions

  1. All of the following are indications for fiberoptic bronchoscopic intubation EXCEPT:
  2. In preparing a patient for bronchoscopic intubation using an oral approach, which of the following are required:
  3. All of the following are true regarding the technique of fiberoptic intubation EXCEPT:


Prepared by: O. Gajic, Mayo Clinic, Rochester, MN Date: June 2003

Prepared by:
O. Gajic M.D.
Mayo Clinic, Rochester, MN June 2003
Reviewed by :
Karen L. Swanson DO
Mayo Clinic, Rochester, MN June 2003

References

Weiss YG, Deutschman CS. The role of fiberoptic bronchoscopy in airway management of the critically ill patient. Crit Care Clin. 2000 Jul;16(3):445-51, vi.

Ovassapian A, Randel GI. The role of the fiberscope in the critically ill patient.
Crit Care Clin. 1995 Jan;11(1):29-51.

Dellinger RP. Fiberoptic bronchoscopy in adult airway management.
Crit Care Med. 1990 Aug;18(8):882-7

Langeron O, Semjen F, Bourgain JL, Marsac A, Cros AM. Comparison of the intubating laryngeal mask airway with the fiberoptic intubation in anticipated difficult airway management. Anesthesiology. 2001 Jun;94(6):968-72.

Jones M, Bramhall J. Airway anaesthesia during fibreoptic endoscopy.
Can J Anaesth. 1997 Jul;44(7):785.