Frequently Asked Questions

Below are some of the most common questions received regarding Flexible Fiberoptic Intubation.

Have you really accomplished more than 6000 fiberoptic intubations?

Yes.  Really.  Starting in October 2004, I kept careful records of all my intubations.  I consistently performed more than 400 endoscopic intubations per year, every year.  In June of 2014, I accomplished my 4000th intubation.  Nothing has changed in my practice since then.  I routinely accomplish forty to fifty flexible endoscopic intubations per month.

Why do I intubate patients facing them?

Well, it’s simply much easier.  The more I sit the patient up, the less gravity pulls the tongue posteriorly.  I can look into the mouth and confirm that my scope is in the midline.  I can hold the scope well back from its tip, such that I don’t have to let it go and reposition my hand as I advance the scope into the airway.  Check out this post for a more detailed look at how I got started intubating patients while facing them and why it matters.

Why don’t you use a ramp?

Three reasons.  One, a ramp is not necessary to elevate the head and torso of the patient.  Simply elevating the head of the bed accomplishes the same thing and better.  Two, having gotten a morbidly obese patient positioned on a ramp, it can be very difficult to remove it.  Third, if you’re going to follow my advice and practice flexible endoscopic intubations a lot, then you’re going to be building a lot of ramps and needlessly adding to your daily workload.

Do you fiberoptically intubate patients after RSI?

Yes.  If the concern is regurgitation and aspiration of gastric contents, then I sit the patient straight upright and have another assistant hold cricoid pressure.  (This question begs another question to the endoscopic naysayer.  What about RSI and the difficult airway?   Are you going to induce unconsciousness and muscle relaxation and then struggle with the airway?)

I know I can intubate a patient with a laryngoscope, why should I intubate them with a fiberoptic bronchoscope?

Easy airways are precisely the ones you should learn on, practice on, teach on, and gain experience on with the flexible endoscope.  You should practice on enough easy airways that you can routinely intubate endoscopically in 5-10 seconds.

Do you recommend any particular brand of bronchoscope or endotracheal tube?

No.  I’ve used Olympus, Karl Storz and Pentax bronchoscopes.  I’ve used Olympus the most, mainly because of its availability at multiple hospitals where I work.  I like the superior optics of Storz, and I have found that the little monitor of the C-Mac system is indispensable for teaching trainees. I like the feel of the Pentax scope in my hand.  I like Parker FlexTip endotracheal tubes because of the soft, flexible tip.  But they are not necessary.

Do I suction secretions with the bronchoscope?

No.  The suction channel is very small and ineffective at sucking up thick secretions.  Further, people commonly forget to rinse it immediately after using it.  The secretions quickly dry in the channel, the scope is “broken” and must be repaired.  A clogged suction channel is probably the most common reason for a broken bronchoscope.

Is the fiberoptic bronchoscope useful in the prehospital setting?

No, I don’t think so.  I think the prehospital community should be utilizing video laryngoscopy technology.  This is increasingly occurring.

Are you saying the fiberoptic bronchoscope should be used in every intubation?

No, not at all.  I am saying that the fiberoptic endoscope is the single most versatile tool for routine, difficult and emergency intubations, orally, nasally, in patients of all ages, shapes and sizes in any position.  Every doctor or mid-level who performs intubations should become an expert in its use.  Of course there are a myriad of situations and scenarios where it obviously would not be the best airway tool.

Do you use an intubating oral airway?

No.  Not necessary and inferior to a well-performed jaw thrust.

Do you soak the endotracheal tube in warm water to soften the tip?

No.  An unnecessary step.  Further, I think it increases the likelihood that the tip of the tube will bend outward, not inward, when it encounters resistance, such as against a vocal fold.

Do you soak the scope in warm water or use defogging solution?

No.  The more stuff one must assemble to perform an endoscopic intubation, the less likely one is to perform it routinely.  I like to keep things very simple.

Why are you anti-GlideScope?

Loaded question.  I’m not anti-video laryngoscopy of any kind.  I’m pro-minimally invasive intubation tools and technique.  Flexible endoscopic intubation is a necessary skill everyone who intubates patients should get very good at.

How do you perform awake fiberoptic intubation?

Once you get really good at flexible endoscopic intubation, you will feel quite comfortable with many airway challenges, including difficult anatomy or circumstances that would have formerly caused you to feel that an awake intubation was indicated.  So I’ve done very few awake intubations.  The ones that I have done, I’ve prepped the patient’s nares with a neosynephrine nasal spray mixed with lidocaine.  (Pop the top of a bottle of neosynephrine nasal spray and add 10-15 ml of 1 or 2% lidocaine to it.  Replace the top, shake it, and give it to the patient.  Have the patient spray it in each nostril and inhale deeply.  Repeat once or twice over the course of 15-20 minutes.)  I use minimal sedation.  I gently advance the scope into the nose and manipulate it into the larynx, then down to the carina.  Then I advance the endotracheal tube over it.  I have not attempted awake oropharyngeal endoscopic intubation.

Have you used fiberoptic intubation for placement of oral Rae or nasal Rae tubes?


What about double-lumen tubes?  NIM tubes?

I’ve only done one endoscopic intubation for placement of a double-lumen tube.  The patient had awful airway anatomy.  I don’t recommend flexible endoscopic intubation for this application.  I’ve placed many neuromonitoring tubes endoscopically, but I think indirect laryngoscopy is a better choice, as this allows you to confirm that the monitoring contacts are situated precisely at the level of the vocal cords.

What is the fastest you have ever fiberoptically intubated a patient?

Many times I have driven the scope from the opening of the mouth to the carina in two seconds.  Advancing the tube and withdrawing the scope then takes a few more seconds.

Have you ever failed to intubate a patient fiberoptically?

Yes.  In 6000 intubations, six times.  I learned from each situation.  One patient produced copious saliva and every time I suctioned it out, she produced more.  Two patients I couldn’t get around the tongue.  I should have gone down their noses. Three patients had severe airway edema from multiple failed attempts at emergency laryngoscopy and had no distinguishable airway anatomy.

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