Why Do I Face the Patient for Fiberoptic Intubation?

Many years ago, I was struggling to intubate a patient endoscopically.  The patient had difficult airway anatomy due to head and neck cancer.  I was standing at the head of the bed, the patient was supine, I couldn’t get the scope around the base of the tongue, and I couldn’t see anything except soft tissue.  The ENT surgeon watched me struggle.  Eventually, I gave up and handed the scope to him.  He intubated the patient quickly and easily.  I was quite embarrassed and nonplussed.

The surgeon said to me, gently and collegially, “I think you guys (anesthesiologists) do it (endoscopic intubation) all wrong.  You should come to my office and I’ll show you how to do it.”

The human psyche is wired such that we tend to respond much more powerfully to negative experiences than to positive ones, and this particular failed endoscopic intubation bothered me immensely.  I was quite unnerved that I had no confidence in my ability to manage a difficult airway, if such management involved endoscopic intubation.

Several months later I made an appointment to see this surgeon.  When I told him I wanted to learn from him how to intubate a patient with a flexible endoscope, he looked equal parts stunned and pleased.  “I wish all of your colleagues would learn how to do it properly,” he said.

“Now we don’t intubate patients very much,” he admitted, “but we do examine their airways and our approach is completely different than yours.  In our office we have our patients sitting upright in a chair.  In the OR we elevate the head of the bed as much as we can.  And we always face the patient.  It’s a much more natural approach to the airway.  Let me show you.”

He then proceeded to anesthetize my nose and sinus passages, gently insert his endoscope, guide it into my nasopharynx, then show me a perfect view of my own glottis on the monitor  It took only seconds, and I was quite impressed at how easily he did the whole thing.

Of course I immediately understood that I was not going to routinely intubate surgical patients nasally.  Nor was I routinely going to intubate patients sitting bolt upright.  But I was intrigued at the idea of facing the patient while attempting endoscopic intubation, and it was obvious to me that elevating the head of the bed would make the task a lot easier. 

It took me quite some time to gain the courage to try his approach to the airway, facing the patient, but eventually I decided to do so.  And I made a commitment to trying this approach until I succeeded.  After only a dozen or so intubations, I realized the truth that an anterior approach to endoscopic intubation is so much easier than a head-of-the-bed approach.

Takeaway point—learn something from our ENT colleagues: it’s much easier to drive an endoscope into the airway when you are facing the patient.  You don’t have your left hand positioned awkwardly up in the air.  The path that the endoscope follows into the mouth, the oropharynx, and then the glottis follows a more natural C-curve, rather than the S-curve described by the head-of-the-bed approach.  You can more easily see into the patient’s mouth as you initially insert the scope, ensuring that it is in the midline and at the back of the mouth before you angle it down and start advancing it.  You can hold your right hand further back on the insertion tube, rather than near or in the patient’s mouth. Perhaps most importantly, you can elevate the head of the bed—all the way up to ninety degrees, if necessary—to make your task that much easier.  If you are trying to endoscopically intubate a patient from the head of the bed, your task will become much more difficult as you elevate the head of the bed.

Finally, there is a subset of patients who, for whatever reason, cannot lie flat.  They must maintain an upright or semi-upright position.  If you are going to attempt to intubate these patients from the head of the bed, well, you just made your job a lot more difficult, if not impossible.

Every clinician who manages airways should become an expert at flexible endoscopic intubation.  Part of this expertise involves learning how to intubate patients while facing them.  Once you learn how to do this, you will quickly realize how much easier it is. 

And this is the main reason why I intubate patients while facing them.  It’s simply much easier.