In cases where a difficult airway is anticipated, fiberoptic intubation is the method of choice since it has a high airway management success rate of around 88% to 100%. This is because fiberoptic intubations offer healthcare practitioners a direct visualization of the pharynx.
Let’s explore what fiberoptic intubations are, their indications and contradictions, and other information pertinent to this airway management procedure!
What Are Fiberoptic Intubations?
Fiberoptic intubations have been used in airway management since the 1960s. They have since been considered the gold standard for managing very difficult anatomic airways with a high chance of can’t intubate/can’t ventilate due to their high success rate.
Though the use of this technique gradually declined due to the introduction of new, updated equipment, it remains an important component of complete airway management. This is because, despite the advanced devices used today, any lapses in airway assessment and strategic planning have dire consequences, making fiberoptic intubations relevant, preferable, and necessary.
The major downside to fiberoptic intubations is it is an extremely challenging technique with a steep learning curve and requires advanced planning. Even if it is mastered, healthcare professionals, particularly anesthesiologists who intubate patients, must regularly practice the procedure to maintain their skills.
It involves loading a tracheal tube along the length of a flexible endoscope and passing it through the glottis. The tracheal tube is then pushed into the trachea so the endoscope can be withdrawn.
Fiberoptic intubations can be performed with utmost ease if the patient is seated or in a supine position.
The patient may or may not be sedated during this procedure while the laryngoscope can be inserted nasally or orally. In cases where the patient is sedated, it is known as asleep fiberoptic intubation. If the patient is not sedated, it is called awake fiberoptic intubation.
Asleep Fiberoptic Intubations
In asleep fiberoptic intubations, different methods may be used while maintaining ventilation with or without an oral airway.
Fiberoptic intubations can also be performed with mask ventilation using an oral airway and Aintree Intubation Catheter.
It is also possible to intubate while ventilating the patient through an LMA when using an Aintree Intubation Catheter or an ETT exchanger.
Asleep fiberoptic intubations can be performed in most patients who require intubation, particularly those with a risk of teeth damage or an unstable spine injury that contradicts direct laryngoscopy intubation.
Absolute contradictions for asleep fiberoptic intubation mainly occur when the healthcare provider lacks proper knowledge and training, or when the patient refuses the procedure.
Awake Fiberoptic Intubations
Awake fiberoptic intubations are performed when the patient is not sedated. They are typically less desirable as the patient may feel discomfort.
However, they are important and necessary, particularly in patients who:
- Have a high risk of aspiration of gastric contents
- Require a neurological exam directly following intubation
- Are prone to difficult intubation
- Have a history of difficult airways and intubation issues
The main contradictions associated with awake fiberoptic intubations are when the patient explicitly refuses the procedure, or when they may be allergic to local anesthetics.
Awake fiberoptic intubations are beneficial as they bypass the need to manipulate the cervical spine, making them useful for patients with spinal issues.
Patients can also maintain their own airways during preparation until the intubation is successfully established, thus reducing the risk of aspiration.
Fiberoptic Intubations in Pediatric Patients
Pediatric patients have smaller airways compared to adults which can make fiberoptic intubations more difficult to perform.
This is because it is challenging to manipulate the fiberoptic in such patients. Even minute movements of the fiberoptic scope’s tip could touch the mucosa of the trachea/nasopharynx.
This can adversely impact the airway visualization while requiring back-and-forth maneuvering of the fiberoptic scope.
As a result, children will consume oxygen at a much higher rate, which can significantly shorten the apnea period that can be safely tolerated. Additionally, the anesthesiologist might have to interrupt the procedure by starting ventilation to avoid severely desaturating the patient.
Awake fiberoptic intubations are also more challenging on pediatric patients because the patient may not cooperate and sympathetic responses such as coughing may also increase.
Fiberoptic Intubations Through a Laryngeal Mask Airway
Patients with difficult airways, particularly pediatric patients, may require blind intubation techniques via the laryngeal mask airway. This is associated with potential trauma and may be unreliable, and is thus only attempted when a bronchoscope is unavailable.
It involves the insertion of a laryngeal mask airway while the patient is breathing spontaneously. Once the patient is under anesthesia, the fiberoptic bronchoscope is used to gain a view of the chords through the laryngeal mask airway.
The bronchoscope is then manipulated inside the trachea to visualize the carina once topical lidocaine is administered via the suction channel onto the larynx.
Tracheal intubation can then be accomplished through a number of ways such as railroading it over the bronchoscope.
Final Thoughts
Fiberoptic intubations remain a valuable ventilation technique in modern medical settings, particularly because they can be performed whether patients are awake or asleep.
They enhance difficult airway management, making them a preferred choice for patients with spinal issues, aspiration risks, and a history of difficult airways.
Though challenging to learn and requiring frequent practice, knowledge of this technique is essential.
If you’re looking to enhance your skills and broaden your knowledge of fiberoptic intubations and other airway management techniques, Hospital Procedures Consultants offers an Endotracheal Intubation Course.
Resources
Wilson, W. Smith, A. The emerging role of awake videolaryngoscopy in airway management. Anaesthesia 2018, 73, 1055–1066
Kollmeier, B. Boyete, L. Beecham, G. Desai, N. Khetarpal, S. Difficult Airway. Continuing Education Activity. 2023.04
Wong, J. Lee, J. Ling Wood, T. Iqbal, R. Wong, P. Fibreoptic intubation in airway management: a review article. Singapore Med J. 2019 Mar; 60(3): 110–118.