Fiberoptic vs Video Laryngoscopy (Indications for Fiberoptic)

Video laryngoscopy (VL) is a valid technique for difficult airway management in awake patients. But for patients with a history of difficult mask ventilation or intubation, awake fiberoptic intubation is widely considered the gold standard. It provides a clear visualization of the vocal cords through a flexible nasal or oral route, and can be used with other techniques like laryngeal mask airway (LMA) and VL.

But which scenarios are fiberoptic intubation (FOI) best for?

Explore the indications for awake FOI with Hospital Procedures Consultants. 

Indications for Awake Fiberoptic Intubations

In clinical scenarios where a tracheal intubation with a mask or supraglottic device (SGD) could be problematic, awake FOI remains the best course of action.

Below are some common indications where this technique may be employed.

Abnormal Anatomy 

In addition to factors like body weight, FOI may be indicated for patients with the below-listed anatomic and anthropometric features. These are predictive of difficult/impossible mask ventilation and intubation.

  • Narrow dental arch
  • Limited mouth opening
  • Increased neck circumference (>16 inches)
  • Limited mandibular protrusion
  • Modified Mallampati class 3 or 4
  • Decreased submandibular compliance
  • Limited head and upper neck extension
  • Decreased thyromental distance

These challenges can lead to higher odds of first-attempt failures. Because video laryngoscopy calls for general anesthesia, which can be difficult due to anatomical abnormalities, awake FOI is emerging as a more useful alternative since it can be performed nasally or orally in patients using topical or regional anesthesia.

Head and Neck Cancers

A significant portion of patients with head and neck pathologies combined with difficult airways are suited for awake FOI. Patients with intubation issues are good candidates for this procedure because such issues are associated with a high rate of morbidity. Based on medical literature, failure occurs in up to 13% of cases. In this scenario, awake FOI must be administered with data from radiographic studies such as computed tomography and magnetic resonance imaging. 

A fiberoptic bronchoscope might be the best option for these events. It allows direct airway inspection, facilitating the diagnosis of benign and malignant airway lesions. A case series study on 17 consecutive oncological emergency patients also found that fiber-optic bronchoscopic intubation is a viable option in head and neck oncological emergencies due to upper airway obstruction and tumor bleeding.

Studies also indicate the emergence of “awake fiberoptic” intubation, a safe and valuable technique for patients with head and neck cancers as well as difficult airways. A 2007 study, for example, showed how it can be used to detect end-tidal carbon dioxide and act as a guide for successfully railroading the preloaded tracheal tube. 

Cervical Spine Instability

Instability of the cervical spine is a more common problem than medical professionals might realize. Unless it’s identified and appropriately treated, it could lead to vertebral and neurological symptoms which could be progressive. However, diagnosis can be difficult as it can be challenging to immobilize the spine during intubation

Research suggests that video laryngoscopy results in less cervical spine movement than direct laryngoscopy and mask ventilation. However, it also shows that fiberoptic-bronchoscopy is better than video laryngoscopy. So, no one technique is better than the other. 

However, awake FOI can be a feasible approach for these patients—and not because it has better intubation success or clinical outcomes. Rather, it helps in maintaining the head and neck in a neutral position during airway management, limiting flexion and extension even in the absence of cervical immobilization. 

It also allows patients to maintain their own airways, reducing the risk of aspiration. Additionally, it ensures cooperation with a neurological assessment following intubation and positioning, and does not raise concerns associated with the use of general anesthesia.

Having said that, some research suggests that awake fibreoptic intubations are excellent with the infusion of remifentanil or dexmedetomidine for treating anxious patients.

Facial or Upper Airway Trauma

Trauma is one of the major causes of death worldwide, claiming approximately six million deaths per year! Speedy and efficient care in emergency situations is vital, especially when there’s a need for oxygenation and ventilation

Direct laryngoscopy is widely considered the technique of choice among patients with maxillofacial trauma—not FOB-guided intubation. This is because of blood, vomitus, and secretions which can obscure the clinician’s view and lead to the inadequate distribution of local anaesthesia due to dilution.

Since visualization of the lower airway is required for intubation and endotracheal tube (ETT) placement, the debate between fiberoptic vs video laryngoscopy may seem irrelevant. This is because if the wrong technique is employed, there could be a risk of severe or catastrophic complications.

A study on a 32-year-old gentleman who suffered from a blunt trauma showed that airway control was achieved with a fiber optic-guided, reinforced endotracheal tube under spontaneous ventilation. For better results, research recommends combining the use of video laryngoscopes with FOB-guided intubation along with a good suction, especially in spontaneously breathing patients with airway trauma. 

Difficult Intubation by Direct Laryngoscopy

If the clinician has reason to anticipate a difficult airway, direct laryngoscopy may not be the best option. In such cases, the administration of a tracheal intubation must be carefully evaluated by obtaining the patient’s medical records and assessing the difficulty of intubation. 

Awake FOI, for one, is the recommended option for anticipated difficult airway management. Moreover, it is also the preferred option for patients at risk of aspiration, a condition associated with pneumonia and a 30-day mortality rate of around 21%.

Learn How to Perform FOI with HPC

Anaesthetizing patients experiencing airway management difficulties can have serious implications. The good news is that FOI has been established as an effective method for gaining airway access among patients with difficult airways—to the point where it became the preferred choice for anesthesiologists in the late 1990s. 

Granted, this was before video laryngoscopy entered the picture in 2001.

However, the evidence suggesting that video laryngoscopes results in faster tracheal intubations is of lower quality. While it can achieve overall and first-attempt success, it’s best to use it as an alternative to awake fiberoptic intubation. The latter offers better safety and can be performed in a variety of settings.

Though fiberoptic intubation for airway management can be a challenging technique to learn, Hospital Procedures Consultants can help you master this procedure. Our experts can teach you the ins and outs of fiberoptic intubation so that you have the skills, familiarity, and confidence to execute it in your medical practice.

Visit our website to learn more about us and our courses.



Moore, A. Schricker, T. Awake videolaryngoscopy versus fiberoptic bronchoscopy. Curr Opin Anaesthesiol. 2019 Dec;32(6):764-768. doi: 10.1097

Simon, L. Torp, K. Laryngeal Mask Airway. StatPearls. 2023 July.
el-Ganzouri, A. McCarthy, R. Tuman, K. Tanck, E. Ivankovich, A. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg

. 1996 Jun;82(6):1197-204. doi: 10.1097

Joshi, R. Hypes, C. Greenberg, J. Snyder, L. Malo, J. Bloom, J. Chopra, H. Sakles, J. Mosier, J. Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit. Observational Study Ann Am Thorac Soc. 2017 Mar;14(3):368-375. doi: 10.1513

Gupta, R. Shani, A. Is video laryngoscopy easier than direct laryngoscopy for intubation in patients with contracture neck?. Saudi J Anaesth. 2020 Apr-Jun; 14(2): 206–211
Yadav, U. Kumar, A. Gupta, P. A Comparative Study of Airway Nerve Blocks and Atomized Lidocaine by the Laryngo-Tracheal Mucosal Atomization Device (LMA MADgic) Airway for Oral Awake Fiberoptic Intubation. Cureus. 2021 Jun; 13(6): e15772.

Published online 2021 Jun 20. doi: 10.7759/ 

Huitink, J. Buitelaar, D. Schutte, P. Awake fibrecapnic intubation: a novel technique for intubation in head and neck cancer patients with a difficult airway. Anaesthesia

. 2006 May;61(5):449-52. doi: 10.1111/j.1365-2044.2006.04586

Liebler, J. Markin, C.Fiberoptic bronchoscopy for diagnosis and treatment. Crit Care Clin. 2000 Jan;16(1):83-100. doi: 10.1016ç

Varghese, B. Balakrishnan, M. Kuriakose, R. Fibre-optic intubation in oncological head and neck emergencies. J Laryngol Otol. 2005 Aug;119(8):634-8. doi: 10.1258/0022215054516160.

Huitink, J. Balm, A. Keijzer, C. Buitelaar, D. Awake fibrecapnic intubation in head and neck cancer patients with difficult airways: new findings and refinements to the technique. Anaesthesia. 2007 Mar;62(3):214-9. doi: 10.1111

Singleton, B. Morris, F. Yet, B. Buggy, D. Perkins, Z. Effectiveness of intubation devices in patients with cervical spine immobilisation: a systematic review and network meta-analysis. Br J Anaesth. 2021 May;126(5):1055-1066. doi: 10.1016/

Agrawal, S. Salunke, P. Gupta, S. Swain, A. Jangra, K. Panda, N. Sahu, S. Gupta, V. Bloria, S. Kataria, K. Bhagat, H. Fiberoptic bronchoscopy versus video laryngoscopy guided intubation in patients with craniovertebral junction instability: A cinefluroscopic comparison. Surg Neurol Int. 2021; 12: 92. Published online 2021 Mar 8. doi: 10.25259/SNI_522_2020

Langford, R. Leslie, K. Awake fibreoptic intubation in neurosurgery. J Clin Neurosci

. 2009 Mar;16(3):366-72. doi: 10.1016

Loh, P. Ng, K. Combining glidescope and fiber-optic for intubation in oral maxillofacial surgery. Journal List  J Anaesthesiol Clin Pharmacol  v.33(2); Apr-Jun 2017

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