laryngoscope is outdated

The Case for Minimally Invasive Fiberoptic Intubation

Hello and thank you for visiting. You are probably here because you have at least some kind of interest in airway management. Good for you. Whether you are a student, a trainee, a researcher, a seasoned clinician, or perhaps even a patient, it speaks highly of you that you wish to explore this topic. It’s a big topic and we’re not going to get into all of it here. There are other resources for that. The aim here is to focus our discussion on minimally invasive airway management, or more specifically, intubation with a flexible endoscope (commonly called a fiberoptic bronchoscope).

Since October 2004, I have regularly performed more than 400 flexible fiberoptic intubations a year, every year. As of this writing (Dec 2019), I have fiberoptically intubated more than 6000 patients utilizing a self-taught technique. (You read that correctly–more than 6000 fiberoptic intubations.) Along the way I learned lots of tips and tricks that make this task incredibly easy to accomplish. I’ve taught this technique to dozens of medical students, residents, fellows and attending physicians. It’s incredibly easy to learn and get good at very quickly. How quickly? How good? We’ll get into that below.

It is estimated that 50 million intubations are performed worldwide each year, half of them in the United States. The most commonly used tool is the rigid laryngoscope, with either the Miller blade (1941) or the Macintosh blade (1943) or some variant thereof. The technique of intubation hasn’t changed appreciably in decades. The operator stands at the head of the supine patient. He extends the patient’s neck, opens the mouth, inserts the blade of the rigid laryngoscope, retracts the tongue, elevates the jaw, exposes the glottis, etc.

Early in their training, carpenters learn how to use how to use a hammer. Like the laryngoscope, it’s an old-fashioned tool that still works very well. But a carpenter quickly puts the hammer away and picks up a nail gun. It’s a better tool and it requires a different, better technique. Rather than a swing and a smash, a touch and a squeeze. A laryngoscope is analogous to a hammer and direct laryngoscopy to a swing and a smash. But after learning how to use a laryngoscope, doctors never put it away. They remain hide-bound to a seventy-five year old airway management paradigm with all its attendant shortcomings, complications, trauma and failures. What about the video laryngoscope? It’s basically a better hammer.

The flexible fiberoptic bronchoscope is more versatile, less invasive, less traumatic, kinder, gentler, safer and an all-round better tool for routine, difficult and emergency intubations. Using the technique I will demonstrate below, the learning curve is short and steep. Counterintuitively, it is much safer and much easier to learn an advanced airway skill (fiberoptic intubation) than it is to learn a basic airway skill (laryngoscopy). Within about a dozen intubations, you will start to feel quite confident in your ability to intubate fiberoptically. A few dozen more and you will be a real pro. One hundred, a Jedi Knight. Two hundred, Master of the Universe. The key is to practice on easy airways. You learn how to ski on green runs, not double-black diamonds. It makes no sense to eschew the fiberoptic bronchoscope until you anticipate or encounter a difficult airway.

All of the surgical sciences have moved to minimally invasive care. Airway management? Um, hardly. To characterize the prevailing paradigm of airway management as inside-the-box thinking would be a disservice to the box. Airway management badly needs a revolution–in thinking and practice. It needs converts to and then champions of minimally invasive intubation. A convert here, a champion there until there is a a sudden and significant shift in the paradigm. (See “The Structure of Scientific Revolutions” by Thomas Kuhn (1962)–one of the most cited academic books ever, about the history and progression of scientific knowledge.) Ask yourself this question: seventy-five years from now, will airway management still be stuck in a paradigm that dates back to World War II?

I hope you find the posts below helpful in your particular practice. If you try the technique I explain and demonstrate, commit to practicing and learning it and take advantage of the tips and tricks, you will get very good at fiberoptic intubation very quickly.