Learning objectives

• Describe the principles, indications, and contraindications of fiberoptic intubation
• Perform fiberoptic intubation
• Describe the possible complications of fiberoptic intubation

Background

• Fiberoptic intubation can be performed in awake (with or without sedation) or anesthetized patients
• Awake fiberoptic intubation is the gold standard for anticipated difficult airways
• Based on the optical characteristics of very thin flexible glass fibers that are capable of transmitting light over their length
• Insulation of these fibers by a glass layer with a different optical density facilitates transmission by the internal reflection of light
• In combination with a light source and lenses on both ends of the fiberoptic bronchoscope, images can be transmitted from the tip of the scope to the eyepiece

Indications & contraindications

• Indications
  • Known difficult intubation or previous awake fiberoptic intubation
  • Anticipated difficult intubation
  • After failed intubation in unanticipated difficult airway
  • Known or suspected difficult mask ventilation
  • Unstable C-spine
  • Abnormal anatomy (congenital airway deformities, head and neck cancers)
  • Face/neck/upper airway trauma
• Contraindications
  • Absolute
    • Patient refusal or inability to cooperate
  • Relative
    • Lack of trained personnel
    • Risk of impending airway obstruction
    • Coagulopathy or bleeding in the airway
    • Allergy to local anesthetic
    • Base of skull fracture (for nasal route)

Technique

Complications

• • Oversedation
  • Respiratory depression
  • Airway obstruction
  • Apnea
  • Trauma
  • Bleeding
  • Laryngospasm
  • Vomiting
  • Local anesthetic allergy
  • Toxicity
  • Risk of aspiration due to loss of laryngeal reflexes

Suggested reading

• Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
• Collins SR, Blank RS. Fiberoptic intubation: an overview and update. Respir Care. 2014;59(6):865-880.

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