Fiberoptic Oral Techniques

Flexible Fiberoptic Oral Intubation

Flexible fiberoptic intubation using the oral route is a rarely used intubation technique in emergency airway management. It requires effective topical anesthesia and a cooperative patient. Secretions, blood, and vomitus–common in emergency airways–also make flexible fiberoptic intubation technically difficult. Some patients with neurologic problems, hypercarbic respiratory failure, or other pathology that depresses consciousness may tolerate an oral airway and endotracheal intubation without response, but for many emergency patients both pharmacologic adjuncts and topical anesthesia are required. If pharmacologic adjuncts are needed, tracheal intubation is usually much faster using standard direct laryngoscopy (with rapid sequence intubation) or with other rigid intubation devices such as video laryngoscopes. Working out to length with a 60 centimeter scope, i.e., not allowing any laxity along the full length of the scope while using an eyepiece is also very challenging for many operators. It is easier with the scope connected to a video camera, or using a video endoscope (with a camera integrated into the distal tip of the scope).

Despite the limitations of flexible fiberoptics in emergency situations, this intubation technique has a definite role in situations of where imaging the hypopharynx and larynx is diagnostically useful and when rapid sequence intubation, or laryngoscopy, are contraindicated (i.e., when rescue ventilation with a face mask or supraglottic airway is not likely to work). Examples when fiberoptics are especially useful include angioedema, Ludwig’s angina, tongue hematoma, laryngeal cancer, upper airway burns, and epiglottis. In some of these clinical scenarios it is much better to bypass the mouth altogether and use a nasal approach. Conversely, nasal intubation is associated with numerous problems, especially in patients requiring long-term intubation. This includes sinusitis (universal after 3 days) and limited tube size (that inhibits bronchoscopy with tube sizes less than 7.5mm).

The oral route with a flexible scope can be more technically difficult than nasal fiberoptic intubation because of the sharp angle around the tongue and back of the mouth. In an unconscious, supine patient the tongue and hypopharyngeal structures fall backward, narrowing the channel that the fiberscope must pass through. Fiberscopes must always move through an open channel. Numerous maneuvers may help open the airway and enlarge the channel for the fiberscope. These include a jaw thrust, pulling on the tongue with a gauze pad, and inserting a laryngoscope to distract the tongue and jaw. Specialized fiberoptic oral airways (i.e., Berman, Ovassapian, and Williams) are very effective for getting around the base of the tongue, protecting the scope from biting, and creating an open channel for the scope to pass through.

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