Ventilator-Assisted Living©

Winter 2000, Vol. 14, No. 4


What Is Fiberoptic Intubation?

Selma Harrison Calmes, MD

During surgery, when a person needs help breathing, an endotracheal tube (breathing tube) is usually placed in the windpipe (trachea). This insures that all ventilation goes to the lungs and does not inflate the stomach. The tube also protects the lungs from aspiration of gastric contents that can lead to aspiration pneumonia, a potentially fatal situation.

Placing an endotracheal tube requires that the plane of the mouth gets “lined up” with the plane of the windpipe. This means straightening out the usual 90o angle between the mouth and windpipe. Anesthesiologists generally use a metal laryngoscope to perform this procedure.

Sometimes this is a difficult procedure with the metal laryngoscope because of arthritis in the neck or jaw, changes from scoliosis or previous surgery, or perhaps from the person's normal anatomy (a receding lower jaw or prominent upper teeth, for example).

photo of FO scopeTo help in these complex cases, anesthesiologists or pulmonologists – the physicians who typically place endotracheal tubes – now can use a flexible fiberoptic (FO) bronchoscope (scope). This device has bundles of very thin flexible glass rods that transmit light from a strong light source and also transmit the image seen at the end of the FO scope. A port for suctioning secretions also travels with the light bundles, and clearing the secretions enables physicians to see better.

The FO scope is very flexible and can easily travel around the sharp angle between the back of the mouth and the windpipe. The FO scope enters the windpipe, and the endo-tracheal tube is slid over the scope, into the windpipe. The physician can actually see that the tube is in the correct place.

The FO scope can be introduced either through the nose or mouth. Local anesthesia (usually xylocaine or cocaine) is sprayed or placed in the nose, mouth, and throat to make the patient comfortable during this procedure and later when the tube is in place. This anesthesia requires time, up to 20 minutes, to take effect. Sedation may also be administered, but usually this procedure is done with the patient awake, for greater safety. In my experience, most patients have little memory of the procedure.

FO intubation is best done electively, not after failing at regular intubation, because secretions and sometimes bleeding occur whenever working in the mouth or nose and make it hard to see through the scope. Also, the necessary local anesthesia is not as effective.

If your anesthesiologist or pulmonologist recommends FO intubation, there is a good reason. They have evaluated your airway and know there may be difficulty placing the breathing tube. They may also know from the past that you are hard to intubate. The decision to use a FO approach is for your own safety. It takes time to do this properly, especially waiting for the local anesthesia to work. Your physician should tell you what to expect with FO intubation.

FO scopes are very expensive equipment, between $6,000-$15,000, but they are worth it. They are now recommended, in the American Society of Anesthesiologists' Difficult Airway Algorithm, for all cases known or suspected to be difficult to intubate. Using this approach has been shown to markedly decrease hypoxic brain injury and death from not being able to intubate during anesthesia, so this new technology is indeed life-saving.

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