Fiberoptic Oral Techniques

There are several different methods of performing orotracheal intubatiion using fiberoptic (i.e., endoscopic) scopes with an overlying tracheal tube.  As an airway management technique, fiberoptic intubation is best used as an initial approach, not after repeat laryngoscopy and resultant bleeding or edema.  It is best in patients who have the time to be adequately anesthetized with topical agents, can cooperate with instructions, and who do not need emergent intubation due to severe hypoxia.  Fiberoptic intubation with a flexible scope is almost never done following the use of muscle relaxants (rapid sequence intubation).  Muscle relaxants have been used for fiberoptic intubation in elective settings when the patient can be continuously ventilated using a special face-mask with a bronchoscopic swivel adaptor that allows the scope to pass through the mask.  These specialized items are rarely available in emergency departments.

Long flexible scopes (60 cm length) are the traditional method, but newer malleable or rigid optical stylets (Shikani Stylet, Levitan optical stylet, or Bonfils scope, for example) have the advantage of easier manipulation and unlike flexible scopes, the tip of these instruments is always recessed within the tracheal tube tip.  This makes these devices better for dealing with secretions or blood that might normally obscure the view of a flexible scope, which is always placed in advance of a tracheal tube.  These devices also have oxygen insufflation ports to help keep the tip clear. Malleable or rigid scopes can also be used to directly lift the epiglottis or tongue. Conversely, flexible scopes must be driven into an already patent channel and accordingly work best when the patient is upright, spontaneously breathing.  An advantage of flexible scopes over any other device, assuming there is enough time, is that they permit precise navigation and ultimate maneuverability around abnormal anatomy.