Fiberoptic Intubation Made Easi(er) Christine Whitten MD Department of Anesthesia Kaiser Permanente San Diego Know Your Scope Check before use: if it won t work during check out, it won t work during intubation Obtain clear image: Adjust focus if hazy Alcohol swab OK to clean lens_ don t get solutions in the scope Don t use solvents (dissolve glue holding fibers together) Confirm tip moves correctly Should move up and down, not left and right Attach working channels to O2 or suction Load the ETT onto the scope BEFORE you start Indications Difficult intubations Morbid obesity Limited ROM neck Inability to open mouth Mandibular hypoplasia Pt won t tolerate induction of anesthesia Anticipated difficult ventilation 1
Fiberoptic Challenging With: Severe tracheal or laryngeal stenosis Copious blood Active vomiting Large amounts of secretions Severe upper airway edema Radiation therapy Cellulitis Keys to Success Good knowledge of the instrument Good preparation of the patient Drying agent: 1 st premed to allow time to work Nasal vasconstrictor: 2 nd premed, even if plan is oral Topicalization: critical Judicious Sedation Prevent fogging: Anti-fog &/or warm the fiber in warm water bath Topicalization is Key Inadequate airway anesthesia leads to coughing, gagging and vomiting No amount of sedation can compensate for inadequate airway anesthesia Minimal sedation may be key to cooperative patient safe from aspiration Tell pt what sensations to expect and the steps to be followed 2
One Way to Topicalize Nasal vasoconstrictor (local anesthetic dilates blood vessels) Nebulized 4% lidocaine (200 mg) over 10 min Top off with aerosolyzed pontocaine/lidocaine mixture Calculate total dose before you start to avoid toxicity Can squirt more through the working channel PRN for lower airway sensitivity Never leave pt alone once topicalization begins suction available Oral vs Nasal Nasal Technically easier (fewer curves in oropharynx, less gag reflex stimulation) Risk epistaxis May need smaller tube Oral Avoids epistaxis More difficult due to greater curving More difficult with macroglossia, short thyromental distance, short or long hyomental distance Often require intubation guide/airway Oral Intubating Guides All designed to move tongue forward, providing more space behind tongue to improve visualization, & to pass fiber and ETT Pitfalls: Fail to move the largest tongues anteriorly May still need to pull tongue forward manually Must be aligned with center of airway Off center placement delivers fiber tip laterally and makes finding and entering larynx problematic 3
Avoid Getting Lost Fiberscope is like a telescope: it only lets you see what s in front of the lens Pointing the fiber tip laterally leads to lost landmarks and disorientation Lateral orientation prevents the tip from going where you want it to go If you can see it but can t get there check alignment of fiber AND guide Using the Fiberscope If oral guide used, place in center of mouth Place fiber in center of mouth or through guide by looking at the mouth/guide- NOT through the scope Introducing while looking through scope tends to place fiber tip lateral Avoid looping insertion cord Looping insertion cord pulls tip laterally Hold tube steady in midline If ETT rotates it will pull fiber away from the larynx Finding the Target Locate the target in the center of your field Don t just push scope forward. If larynx is to side of your view when you advance, fiber tip will slide to side of larynx Use tip deflection and tip rotation to aim: Both are controlled at the body of the scope, not the tip 4
Aspiration Risk Aspiration more common in deeply sedated patients with airway obstruction Struggling to breathe increases intrathoracic P and decreases esophageal competency Supraglottic pressure (assisted ventilation with obstruction) forces gas into the stomach and predisposes to vomiting Full stomach Patient Position Patient Supine: Operator behind patient at head of bed Standard views: right is right, up is up More curves in the fiber makes control more challenging Patient Sitting Operator to the side, facing patient Anatomic orientation rotated 180 o : right is left, up is down - Stay oriented using the view marker The Floppy Epiglottis Pull tongue forward Stick tongue out (awake) Jaw thrust Deep, panting breaths pulls larynx posteriorly and downward as airway opens maximally Sit patient up Guide fiber tip over and under epiglottis 5
Difficulties Railroading the Tube Tube tip may catch on laryngeal structures, especially arytenoids Selecting optimal size ETT: Minimize gap between fiberscope and tube wall by choosing a size just larger than fiber, but not too small (don t wrinkle coat of finer) Choose more flexible ETT and/or pre-warm Hold up at right arytenoid most common: rotate ETT 90 o counterclockwise while advancing Verify Proper Tube Placement Once you think you re intubated, it s tempting to immediately inject in the propofol. STOP AND VERIFY FIRST!! Tube tip may be in trachea, but not main body of ETT Make sure cuff is below the cords AND below the cricoid 6