Fiberoptic Intubation

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Dr. Wesam Farid Mousa
Assisstant Professor Anesthesia & ICU
Dammam Hospital of the University

2. Basics of Fiberoptic Intubation

3. 1897
First rigid bronchoscopy
he removed a bone (11Χ3 mm) from right main stem
bronchus
Gustav Killian, M.D.
1860-1921 Mainz, Germany

4. Shigeto Ikeda, M.D.
First flexible fiberoptic bronchoscopy
Japan, 1966

5. • Definitive history or
anticipated difficult
intubation
• Known or suspected
cervical spinal injury
or disease
• ? failed intubation

6. Fiberoptic intubation modes
Anesthetized oral
Anesthetized nasal
Awake oral
Awake nasal

7. Discussion with the patient for:
Safety vs comfort
Feeling of inability to breath
Coughing
Chocking
Speech changes
Early signs of lidocaine toxicity
prepartion for awake fiberoptic intubation

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ASA monitors to be applied

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Sedation
Fentanyl and midazolam most widely used.
Dexmeditomidine, alfentanyl, remifentanyl and propofol are
suitable alternatives
My dear: Anesthesiologist is sick today

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Take home message#1
The goal is to provide conscious sedation to afford comfort and
amnesia

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Be ready for GA
Be ready for emergency airway
Be ready for systemic toxicity of local anesthesia

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Anesthesia of oral cavity & pharynx-
Non invasive: Topicalization
Invasive: Glossopharyngeal nerve block
Anesthesia of the larynx:
Above vocal cord:internal branch of superior laryngeal nerve
Below vocal cord: recurrent laryngeal nerve.
Anesthesia of the trachea
Anesthesia of the airway

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A: Topicalization
Lidocaine nebulization and atomization
Cotton-tipped swabs soaked in lidocaine left for several minutes
in mouth or nose
Spraying through the work channel of the scope
Also we can use:
Lidocaine 5% ointment
Lidocaine lollipop
Lidocaine 4% gargle
EMLA cream
Anesthesia of the airway
Atomization is conversion of bulk
liquid into a spray by passing the
liquid through a nozzle.
• Place 5 ml of 4% lidocaine into a nebulizer,
• Highly effective.
• risk of systemic toxicity.
10% solution of lignocaine
Sprayed at tongue, fauces, soft palate, uvula & posterior
oropharyngeal wall
Protrude tongue; sprayed lateral & posterior laryngopharyngeal
wall
Approximate; 4-5 metered sprays

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glossopharyngeal block
easily accessed as they transverse the
palatoglossal folds .
A 25g needle is inserted into the
membrane near the floor of the
mouth at the anterior tonsillar pillar
0.5 cm lateral to the base of the
tongue.
advanced slightly (0.25-0.5 cm).
2 ml of 1% Lidocaine can be
injected.

15. Anesthesia for the nares.
• Progressively larger sized soft nasal airways
coated with 2% lidocaine.

16. Vagus nerve branching into Superior Laryngeal and
Recurrent Laryngeal nerve.
Note the insertion of Superior Laryngeal Nerve into
ThyroHyoid Membrane.
superior laryngeal block – larynx above the cords

17. Tracheal anatomy depicting Superior Laryngeal
Nerve with the internal and external branch.

18. superior laryngeal block – larynx above the cords
requires neck extension.
Identify the greater cornu of the hyoid
bone and superior cornu of the
thyroid cartilage.
Pressing the contralateral greater
cornu of hyoid bone, laryngeal
structure to be displaced towards the
side to be blocked.

19. • At a depth of 1-2 cm, 2 ml of 2% lidocaine
with epinephrine is injected into the space
between the thyrohyoid membrane and the
pharyngeal mucosa.
• The block is repeated on the other side
22 or 23 guage – 25 mm
needle is "walked off"
the cornu of the hyoid
bone in an anterior
caudad direction, aiming
in the direction of the
thyroid ligament, until it
can be passed through
the ligament.

20. Technique Tips!
• caution - not to insert the needle into the thyroid
cartilage, since injection of local anesthetic at the
level of vocal cords may cause edema and airway
obstruction.
• If air is aspirated, laryngeal mucosa has been
pierced, and the needle needs to be retrieved.
• If blood is aspirated (superior laryngeal artery or
vein), the needle needs to be redirected more
anteriorly. Pressure should be applied to avoid
hematoma formation.

21. This is more correctly described as
a method of topically applying
local anesthetic to the trachea and
larynx.
Translaryngeal “Transtracheal” block :–
larynx and trachea below the cords
place index and third fingers of the non-dominant hand in
the space between the thyroid and cricoid cartilages
The trachea can be held in place by
placing the thumb and ring finger
on either side of the thyroid cartilage
. The midline should then be identified

22. • Immediately after the
introduction of the catheter
into the trachea, a loss of
airway resistance and
aspiration of air confirms
placement, and the needle is
removed from the catheter.
• The patient is then asked to
take a deep breath and then
asked to exhale forcefully
• At the end of the expiratory
effort, 3-4 ml 2% lidocaine
solution is rapidly injected
into the trachea.

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Signs of effective airway anesthesia
Speech changes: difficulty getting words out, slurred speech, pitch
changes, hoaseness
No gagging on deep touch to posterior third of the tongue and
pharynx

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Take home message #2
Sedation will not compensate for poor topicalization

25. Setup the fiberoptic scope.
“A place for everything and everything
in its place."
• Place the bronchoscope and its cart on the
left side of the patient .

26. Open up the airway
Devices to Aid Fiberoptic Intubation.
 Intubation via Airways:
oral.
o Olympus bite block.
o Williams airway.
o Ovassapian airway.
Nasal.
 Intubation via Endoscopy Mask.
Patil mask.

27. Intubating oral airways
• Prevent trauma to the fiberscope from the
patients teeth.
• Guide to the fiberscope to position it in midline
towards the glottic opening.

28. Olympus bite block
Advantages..
• Large internal
diameter: possible to
use variety of sizes of
endotracheal tube.
• Short length:
comfortable for use in
an awake patient.

29. Disadvantages
• Not a useful guide for
the fiberscope.
• Chances of tube
dislodgement while
removing bite block.

30. Williams airway
• Longer piece serves
as a better guide to
the fiberscope.
But
increases likelihood of
tube dislodgement.
• Not comfortable to an
awake patient.

31. Ovassapian airway
Same length & curvature as williams airway and :
similar problems
Advantage: Dorsal openings allowing it to be
removed without sliding over the tube.

32. Patil mask
• Adapter through
which the fiberoptic is
introduced.
• Mask permits non
invasive ventilation of
the patient during the
intubation process.

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Push the tongue
caudally with tongue
depressor on middle
of tongue: it will pop
out.
Tongue pulling out
Open up the airway

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Hold the tongue
with a gauze
and pull it out
Tongue pulling out

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Pulling out tongue will elevate the epiglottis away from the
posterior pharyngeal wall
Take home message #3

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1) Eye piece: Can be attached to a camera for display
on screen
2)Diopter ring for focusing3)Control lever: Controls the tip4)Working channel port: For suction, instillation of
local anesthetic, oxygen delivery.
5)Body: Incorporates the eye piece, diopter ring,
control level and working channel. Grasped by the
operators non-dominant hand.
6)Insertion cord: Contains fiberoptic bundle for light
and image transmission
7)Light source: Can be a portable battery powered
source or via a cable
8)Suction valve and port
Anatomy of the bronchoscope

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Flexion lever moves tip of the scope from
06:00 to 12:00 in one plane
Tip at 06:00 position Tip at 12:00 position

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Flexion lever moves tip of the scope from
06:00 to 12:00 in one plane

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To flex the tip in other planes, rotate the entire scope

40. Fiberscope with endotracheal
tube mounted .

41. Fiberscope with laryngeal mask
airway mounted.

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Small tubes (6.0-6.5 mm for female
patients and 7.0 mm for male
patients) advance more easily.
The size discrepancy between
the fiberoptic bronchoscope
and the tracheal tube that has
been threaded onto it can
create a cleft that can entrap
anterior anatomic structures,
hindering advancement of the
tracheal tube into the larynx
(hang-up).

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Marker to be put at 12;00 to maintain spatial orientation

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Line up the fiberoptic shaft .
Know where that tip points before it
disappears from view!

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As in laparoscopic
surgery either at right or
left of the patient
depending on the
dominant hand
Position of the anesthesiologist

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Position of the anesthesiologist

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Hand position
Dominant hand
is put proximal
to the patient
and holds the
scope as a pen
Stand on a lift so that the fiberoptic bronchoscope shaft will be
straight when you hold it above the patient.
The head of the fiberscope is held in the right hand, with the right
thumb on the control lever.
With your left hand, hold the bronchoscope shaft at a point 15 to 20
cm from the shaft tip.

48. (A) The handle is held in the
nondominant hand with the
tip of thumb over the
sagittal plane control lever.
The index finger can be
used to control the working
channel (e.g., suction,
oxygen insufflation). The
dominant hand is used for
fine manipulation at the
distal end. (B) The
operator's two hands should
be kept maximally apart so
as to keep the insertion
shaft as straight as
possible, maximizing
coronal plane rotational
control. (C) Curves
48
Handling of the fiberopticbronchoscope.

49. Patient positioning for fiberoptic
intubation..
classical sniffing position:
• Places the epiglottis against the posterior
pharyngeal wall, causing difficulty in
maneuvering the fiberscope under the
epiglottis.
Neutral position
• The chin lift and jaw thrust maneuvers,
move the soft tissues and lifts the
epiglottis from the posterior pharyngeal
wall improving the view through the
fiberscope.

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Defog the tip by
Defogger
Warm water
Against buccal mucosa

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Pink color is seen if you
position the scope
against tongue suface
Now you are ready to go

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Flush with scope on the tongue in
the midline towards the uvula
Uvula
Bottom of the tongue
- The patient is then asked to
take a deep breath and the
bronchoscope is passed through
the cords.
-If this precipitates coughing,
additional lidocaine can be
sprayed through the working
channel of the bronchoscope .

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Keep the tongue in the
botom half of the view
by rotating the hand
holding the tip of the
scope

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Keep lumen of the
airway centered
Keep tongue in view

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Once epiglottis is seen,
ask the patient to take
deep breath and ask the
assisstant to thrust the
jaw forward
This will move epiglottis
anteriorly away from the
posterior pharyngeal wall

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use the lever to flex or
extend the distal end of
the scope
Advance the scope into
the trachea

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Determine the right and left
main brochi
Do not touch the carina

58. • After passing through the vocal cords the fiberscope is
advanced until the tracheal rings come into view and the
carina becomes identifiable.
• When the tip of the fiberscope is at the carina, the next
step is to pass the endotracheal tube.

59. • If the fiberscope passes through the vocal cords, but the
endotracheal tube does not pass, the tube may be getting
caught on the arytenoid cartilages. Rotating the endotracheal
tube ninety degrees counterclockwise directs the tip into the
trachea.

60. Happy sight

61. Sad sight.

62. CONTRAINDICATIONS TO FIBEROPTIC BRONCHOSCOPY
1. Hypoxia
2. Heavy airway secretions not relieved with suction or
antisialagogues
3. Bleeding from the upper or lower airway not relieved with suction
4. Local anesthetic allergy (for awake attempts)
5. Inability to cooperate (for awake attempts)
62

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Take home message
Center the lumen: by rotating the handle of the scope
Keep the tongue in view: Flex or extend the tip of the scope
Advance the tip of the scope with the index finger

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