Fiberoptic Oral Techniques

Role of Fiberoptic Oral Airways

Tracheal intubation via the mouth with a flexible fiberoptic scope can be more technically difficult than nasal intubation because of the sharp angle in the back of the mouth. Also, the patient must be effectively topicalized (sometimes sedated) to tolerate an oral airway.  In the unconscious person the tongue and hypopharyngeal structures fall backward, narrowing the channel that the fiberscope must pass through. Jaw thrust, provided by an assistant, along with use of a specialized intubating oral airway, is recommended when using the oral route for flexible fiberoptic intubation.

Oral airways for fiberoptic intubation: 

Berman, Williams, and Ovassapian airways (from left to right):

The Berman, Williams, and Ovassapian airways are modified oral airways specifically designed for oral fiberoptic intubation. They each guide the tracheal tube and scope around the tongue and protect the scope should the patient bite down. The Willams airway requires removal of the tracheal tube 15 millimeter connector so that after intubation the airway can be slid out over the tracheal tube, while the Berman and the Ovassapian have a specialized groove to allow removal of the airway after tube placement. Unless deeply obtunded, topical anesthesia and sedation are necessary for the patient to tolerate an oral airway.

After placement of the oral airway (with the tracheal tube not extending beyond the end of the airway), the scope is inserted through the tube and advanced past the oral airway. The laryngeal structures should be visible, assuming the oral airway has been kept midline. Advance the fiberscope gently and smoothly with special attention paid to the counterclockwise rotation of the tracheal tube off the scope when at the level of the laryngeal inlet (14-16 cm).  This CCW rotation is recommended with tracheal tubes that have a standard left-facing bevel.