Common Objections and Responses to Fiberoptic Intubation

Below are the most common objections and questions received regarding Flexible Endoscopic Intubation and the methods discussed on this website.

My biggest issue with the routine use of flexible fiberoptic bronchoscopy is that my hospital simply cannot afford to buy a lot of bronchoscopes.

(I’ll assume that the OP is relaying an objection from hospital administration, so my comments should not be construed as being disrespectful to the OP.)

In my opinion, this objection shouldn’t be an objection.  Your hospital administrators need to ask themselves an obvious question:  Do we want to be a modern hospital or not?  The simple truth is that when it comes to airway management, the price of modernity is much less than the price of failure to modernize.  Flexible bronchoscopes are ridiculously cheap compared to airway catastrophes and the legal claims they engender.  The same hospitals that regulate that patient falls, DVTs, PEs, catheter sepsis and other complications of iatrogenic care should be “never events,” do NOT insist that airway catastrophes should be never events.  The same hospitals that immediately mobilize very expensive resources to TREAT stroke, cardiac arrest, respiratory arrest, trauma, and sepsis, do not want to allocate relatively inexpensive resources to PREVENT airway disasters.  The inside-the-box bias of anesthesia department chairs, surgery department chairs, medical directors, chief medical officers, chief financial officers, chief executive officers and other administrators that we remain entrenched in a seventy-five year old World War II paradigm of airway management makes no sense in a modern era of minimally invasive technology and zero defect expectations.  Ask the naysayers an obvious question: Seventy-five years from now, are we still going to be stuck in a WWII paradigm of airway management?  If not, how are we going to get to a better standard?  How many patients have to suffer severe anoxic brain injury or death before we stop accepting the status quo as the best we can do?  How are we going to make airway catastrophes never events?

Fiberoptic bronchoscopes are fragile and easily broken.

First, not all bronchoscopes utilize fiberoptic technology.  Karl Storz scopes use Distal Chip technology as part of the C-Mac system.  They are significantly less fragile than fiberoptic scopes.  But in my experience, fiberoptic bronchoscopes get broken mainly because people don’t know how to use them or handle them.  They fail to rinse the suction channel after aspirating secretions through it.  They place the scope hanging over the front of their equipment cart and inadvertently close a drawer on it.  They coil the scope too tightly in their hands and break the fiberoptic bundles.  People who use flexible bronchoscopes regularly do not make these mistakes.  They are much less likely to break them because they know how to handle them and how not to handle them.  So counterintuitively, the key to bronchoscopes not getting broken is for people to use them more often, not less.

My hospital does not have the resources to clean a bunch of bronchoscopes throughout the workday.

See the answer to the affordability question, above.

I disagree with elevating the head of the bed after giving induction doses of intubating medications.

If you are concerned about hypotension after induction of anesthesia, then check the patient’s blood pressure before elevating the head of the bed.  You could preempt or treat low BP with judicious amounts of ephedrine or phenylephrine.  And I’m not aware of any statement in any textbook that claims patients must be induced and intubated in the supine position.  Indeed, in some instances, say a full stomach, elevating the head of the bed before induction of anesthesia is considered entirely appropriate.

I’m not comfortable leaving the head of the bed to intubate.

Well, you could continue to attempt endoscopic intubation from the head of the bed.  There are numerous disadvantages to doing this, and it is more difficult, but it is entirely up to you.  You must position your right hand close to the tip of the scope, as you enter the mouth, then let go of the scope and reposition your hand as you advance the scope.  While you are doing this, the endotracheal tube will have slid down the scope, be on top of your hand and basically getting in your way.  You must hold your left hand with the handle of the scope in it high up in the air.  This is needlessly awkward.  The more you elevate the head of the bed, the more difficult all of this becomes.  And you might encounter situations where you cannot easily or quickly get to the head of the bed.  Or you could intubate from the front of the patient as I have described until you become comfortable with this.  With proper positioning and a well-performed jaw thrust, this will take you less than a dozen attempts.  It only takes 5-7 seconds to move from the head of the bed to the patient’s right side.  The intubation should only take you 5-10 seconds.  Then another 5-7 seconds to move back to the head of the patient.  You’ve left the head of the bed and returned to it in less than half a minute.  I think this is entirely reasonable.

We’ve had several bronchoscopes stolen.

Then secure them in a locked cabinet.

I work mainly in a small surgery center and we do not have the room for, nor can we afford a fiberoptic bronchoscope and the cleaning equipment it would require.

There are now single-use flexible bronchoscopes on the market.  They are a perfect solution for the situation you describe.  Please bear in mind that increasingly it is becoming indefensible for surgery centers not to have a full complement of difficult airway equipment, including flexible bronchoscopes.  If your surgery center cannot afford a single-use flexible bronchoscope, can it afford the liability claim of an airway catastrophe?

I disagree with using a fiberoptic bronchoscope for routine intubations.  I think it should be reserved for difficult airways.

First, one gets good at flexible endoscopic intubation by practicing (a lot), and such practice is most easily accomplished on routine airways.  Second, endoscopic intubation skill once obtained, must be maintained, and this requires regular practice, again, on routine airways.  Third, it makes no sense to me to reserve a tool and technique that is kinder, gentler, safer, less traumatic, more versatile and all around better for only a few intubations here and there.  Why not employ the best and safest tool and technique all the time?  Isn’t this the kind of care you would want for you and your loved ones?  Finally, I know of no bedside test that can reliably predict the ease or difficulty of intubation with a high degree of sensitivity and specificity.

My colleagues and I are very good with direct and video laryngoscopy, as well as with multiple supraglottic airway devices.  We haven’t had a failed intubation in years.  I disagree with your assertion that we should all become experts at fiberoptic intubation.

I’m wondering how well your laryngoscopy skills would apply to the patient whose mouth you could not open.  The patient whose neck is permanently flexed?  The patient with massive glossitis?  With severe angioedema?  With severe epiglottis?  There is no laryngoscope, nor is there any supraglottic airway that is a good solution here.  These situations require great skill with a flexible bronchoscope, and as I have stated before, such skill is best acquired and maintained via routine intubations.  Also, if you haven’t had a bad airway outcome in years, then you are most likely overdue.

It seems to me that if I intubated every patient fiberoptically, my laryngoscopy skills would deteriorate.

This is a good thing.

The rigid laryngoscope has been around for decades.  Direct laryngoscopy changed the scope of anesthesia care and surgical care with it.  It is tried and true technology and I see no point in discarding it.

The Minimally Invasive Train is leaving the station and the Zero Defect Train is right behind it.  You need to get on board or get left behind.  The Luddite train is stuck permanently in Yesterdayville.