Tips and Tricks for Fiberoptic Intubation

Here are several tips and tricks to help you become adept at endoscopic intubation very quickly.

1. Unless contraindicated, give the patient glycopyrrolate (0.1 mg IV) several minutes before intubation to reduce saliva formation.

2. To allow the endotracheal tube to pass more easily through the vocal folds, lubricate the cuff with a water-soluble lubricant.  Consider using a flexible tip endotracheal tube, such as the Parker FlexTip as well.

3. Mount the tube all the way up to the handle of the bronchoscope and hold it there with your right hand while performing bronchoscopy.

4. Hold the bronchoscope with your thumb and forefinger, as you would hold a throwing dart.  Do not hold it with your palm supinated.

5. Hold your hands far apart from each other, your left hand on the handle of the scope and your right hand at the end of the endotracheal tube.  Positioning your hands close to each other will create a curve in the scope that will make it more difficult to rotate the tip of the scope laterally.

6. If you are having trouble visualizing any recognizable airway structures, first check the patient’s position.  Try elevating the head of the bed more.  Second, check that your assistant is performing the jaw thrust properly.  Third, use a Yankauer suction to remove secretions.  Fourth, confirm that the bronchoscope is in the midline and is angled properly.  Fifth, if necessary, advance the scope blindly past the base of the tongue and look for an opening in the soft tissue.

7. If you can see the glottis, but are having trouble getting to it, first center it in your field of view before advancing the scope.  Second, reduce the downward curvature of the tip of the scope as you approach the glottis. Third, remove the pillow from behind the patient’s head.  Fourth, position the scope such that it is aligned with the center of the patient’s body.  Fifth, check to see if you need to elevate the head of the bed more.  Sixth, make sure your hands are not positioned too closely together, creating a deep curve in the scope and hindering your ability to rotate it laterally.

8. If after successfully intubating the patient your view through the scope becomes blurry, such that you are unable to visualize airway structures or the tube in the airway, it might be due to secretions or lubricant on the tip of the scope, try flicking the tip of the scope back and forth against the wall of the trachea.  Use your thumb on the angulation control lever to do this.  If this doesn’t help, remove the scope, wipe the tip and reinsert it.

9. To give yourself more time to accomplish intubation, try utilizing extremely high flow nasal cannula oxygen.  Attach the oxygen tubing firmly to the oxygen flow meter and turn the control knob all the way open, until you can turn it no more.  This will result in oxygen flow of up to 70 liters per minute.  Such extremely high flow of oxygen into the nares will improve oxygenation even though the patient is apneic.  You will have more time to intubate the patient before the patient’s oxygen saturation declines.           

10. Remember the three things you won’t find in any textbook:

No textbook says patients MUST be intubated in the supine position.  In the early days of direct laryngoscopy, it was performed with the patients seated in an upright position.  Fiberoptic intubation is much easier with the patients positioned upright or semi-upright.

No textbook says you MUST stand at the head of the bed to intubate a patient.  In many cases, it is much easier to intubate a patient from the front.  Fiberoptic intubation is much easier to accomplish facing the patient.

No textbook says that you are NOT allowed to cheat.  You are allowed to cheat.  You are allowed to sit the patient upright.  You are allowed to enlist someone to pull the jaw forward for you.  You are allowed to look away from the monitor or the eyepiece to re-position the scope in the patient’s mouth.