Overview
Fiberoptic intubation (FOI) is an advanced airway management technique that uses a flexible fiberoptic bronchoscope to visualize the airway and guide endotracheal tube placement. It is particularly valuable for difficult airway management and awake intubation.
FOI is essential for managing difficult airways, especially in patients with limited mouth opening, cervical spine pathology, or airway masses. It allows for awake intubation, preserving spontaneous ventilation and airway reflexes. Mastery of this skill is crucial for anesthesia practice.
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Indications
Known or suspected difficult airway
Trismus, temporomandibular joint disease
Cervical spine injury, ankylosing spondylitis
Tumors, abscesses, or foreign bodies
Preserving spontaneous ventilation
Rescue technique after failed laryngoscopy
Severe facial injuries
Altered airway anatomy
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
Check off items as you gather them:
Pre-procedure Preparation
Preparation includes patient assessment (airway evaluation, contraindications), equipment check (fiberoptic scope, endotracheal tubes, local anesthetic), understanding awake vs. asleep techniques, and proper patient positioning and sedation.Step-by-Step Procedure
Step 1: Patient Preparation
Assess patient, explain procedure, obtain consent, and prepare for awake or asleep technique. Administer anticholinergic to dry secretions.
⚠️ Common Mistakes to Avoid:
- Inadequate explanation
- Poor patient preparation
- No anticholinergic
💡 Pro Tip:
Take time to explain the procedure to the patient. Good communication improves success.
Step 2: Equipment Setup
Check fiberoptic scope function, attach endotracheal tube, test suction, and prepare local anesthetic. Ensure adequate lighting.
⚠️ Common Mistakes to Avoid:
- Broken scope
- Wrong tube size
- Poor lighting
- No suction
💡 Pro Tip:
Always test the scope before starting. Check light source and suction function.
Step 3: Local Anesthesia
Apply local anesthetic to nasal passages, oropharynx, and larynx. Use lidocaine spray, gel, or nebulized solution.
⚠️ Common Mistakes to Avoid:
- Inadequate anesthesia
- Toxic doses
- Poor technique
💡 Pro Tip:
Use appropriate doses of local anesthetic. Monitor for toxicity signs.
Step 4: Scope Insertion
Insert scope through nose or mouth, advance to pharynx, identify epiglottis, and navigate to laryngeal inlet.
⚠️ Common Mistakes to Avoid:
- Poor scope control
- Wrong angle
- Inadequate visualization
💡 Pro Tip:
Keep the scope midline and use gentle movements. Follow the airway anatomy.
Step 5: Vocal Cord Visualization
Identify vocal cords, confirm they are open, and advance scope through glottis into trachea.
⚠️ Common Mistakes to Avoid:
- Wrong identification
- Forcing through cords
- Poor visualization
💡 Pro Tip:
Look for the white vocal cords and the dark space between them.
Step 6: Tube Advancement
Advance endotracheal tube over the scope, confirm position with capnography, and remove scope.
⚠️ Common Mistakes to Avoid:
- Tube catching on cords
- Wrong tube size
- Poor confirmation
💡 Pro Tip:
Use wire-reinforced tubes to prevent kinking. Confirm position with multiple methods.
Step 7: Position Confirmation
Confirm tube position with capnography, auscultation, and chest X-ray if needed.
⚠️ Common Mistakes to Avoid:
- No confirmation
- Relying on single method
- Poor documentation
💡 Pro Tip:
Always confirm position with multiple methods. Capnography is essential.
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Post-procedure Care
Post-procedure care includes confirming tube position, monitoring for complications (airway trauma, infection), assessing for post-procedure sore throat, and documenting the procedure details.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Airway trauma | 5-15% | Bleeding, pain, hoarseness, dysphagia | Observation, analgesics, ENT consultation if severe | Gentle technique, adequate lubrication, proper scope size |
| Local anesthetic toxicity | 2-5% | Metallic taste, tinnitus, seizures, cardiovascular collapse | Stop administration, supportive care, lipid emulsion | Calculate safe doses, monitor for toxicity signs |
| Laryngospasm | 3-8% | Stridor, desaturation, increased airway pressure | Deepen anesthesia, CPAP, muscle relaxants if severe | Adequate local anesthesia, gentle technique |
| Scope damage | 1-3% | Poor visualization, broken fibers, malfunction | Replace scope, document damage, repair if possible | Gentle handling, proper storage, regular maintenance |
| Infection | 1-2% | Fever, purulent secretions, pneumonia | Antibiotics, cultures, monitoring | Proper scope cleaning, sterile technique |
| Failed intubation | 5-10% | Inability to visualize cords, scope malfunction | Alternative techniques, call for help, consider surgical airway | Practice, good technique, backup plans |
Clinical Pearls
Practice regularly - FOI is a skill that requires frequent practice.
Use adequate local anesthesia - patient comfort improves success rate.
Keep the scope midline - this provides the best view of the airway.
Identify landmarks carefully - epiglottis, arytenoids, vocal cords.
Document the procedure - technique used, complications, success rate.
Use wire-reinforced tubes - they advance more easily over the scope.
Have backup plans ready - FOI can fail, know your alternatives.
Monitor for complications - especially local anesthetic toxicity.
Choose appropriate scope size - too large can cause trauma.
Consider awake vs. asleep technique - each has advantages and disadvantages.