Perhaps the single most common reason for the reluctance of clinicians to attempt flexible endoscopic intubation is lack of experience, and therefore skill, with the bronchoscope. There seems to be widespread perception that endoscopic intubation is difficult and time-consuming. Nothing could be further from the truth! With the proper technique and about a dozen attempts, the typical clinician can become very good at flexible endoscopic intubation. Let me describe to you a technique I taught myself and have utilized successfully in over 6000 intubations.
First, elevate the head of the bed. The more difficult the airway, the more the elevation. If need be, sit the patient straight upright. Now this may seem a bit odd at first, but such positioning offers several advantages. It greatly reduces the tendency of the tongue to fall back onto the posterior pharyngeal wall, impeding your view of the glottis. It allows the patient’s neck to extend naturally as the head of the bed is raised. And it helps sub-mental soft tissue as well as large breasts sag downward, out of your way. If there is a contra-indication to elevating the head of the bed, then of course you shouldn’t do this. And if you have induced general anesthesia and are concerned about hypotension in the upright position, you might consider pre-treatment with ephedrine or phenylephrine.
Second, approach the patient from the front, preferably the patient’s right side. This also is an unusual notion, but it offers several advantages over attempting endoscopic intubation from the head of the bed. It allows you to see directly into the patient’s mouth as you introduce and advance the bronchoscope. It helps you re-orient yourself if you wander off the midline. Most importantly, such an approach complements the positional benefits of the upright position. As the patient is positioned more upright, it will become increasingly awkward and difficult to intubate from the head of the bed. It is much easier to intubate endoscopically facing the patient, with the head of the bed elevated.
Third, have an assistant stand at the opposite side of the patient and perform a jaw-thrust maneuver. This will bring the mandible forward and the tongue with it, enabling you to easily advance the bronchoscope around the base of the tongue and then visualize the glottis. Done properly, this maneuver will make your job a lot easier; done improperly, it will make your job a lot harder. Your assistant may stand either at the head of the bed or at the patient’s left side, however as the head of the bed is elevated, it will become obvious that the jaw thrust is most easily accomplished when facing the patient. It is important for your assistant to understand what to do and what not to do. They should place their middle fingers on the ramus of the mandible and pull it forward. Then they should use their thumbs to open the mouth. It is important that they not press into soft tissue under the mandible as this will push that tissue into the oropharynx. It is also critically important not to push the mandible down when opening the mouth, as this will defeat the entire maneuver.
At this point, intubation becomes incredibly easy. Look into the patient’s mouth, advance the bronchoscope to the posterior oropharynx, then angle it down. Now and only now, look at the monitor (or into the eyepiece). As airway structures become visible, center them in your field before advancing toward them. Pass the scope between the vocal folds and advance it all the way to the carina. Now stop looking at the monitor (or eyepiece). Align the bronchoscope in the patient’s midline and orient the endotracheal tube such that its natural curve will follow the curve of the patient’s airway. Slide the tube down the bronchoscope and advance it gently into the trachea. Now look again at the monitor (or into the eyepiece). Confirm that the bronchoscope is still positioned inside the patient’s airway. That is, look for any recognizable airway structures, such as tracheal rings or bronchi. Now withdraw the scope until you visualize the endotracheal tube. Remove the bronchoscope from the airway, being careful not to dislodge the endotracheal tube. Congratulations! You have successfully performed a flexible endoscopic intubation! As you practice this skill and accumulate intubations, you will very quickly be able to accomplish a typical intubation in a matter of seconds.