Chapter 10

The flexible fiberoptic bronchoscope has become a popular and useful instrument for placing endotracheal tubes in awake and nonparalyzed patients. It is unique in that its flexible cord allows it to conform to the patient’s anatomy, making intubation possible in a variety of clinical situations when intubation by direct laryngoscopy is likely to be difficult or impossible.When performed properly, awake fiberoptic tracheal intubation is more accepted by patients and is associated with fewer hemodynamic changes than awake laryngoscopy.1 It may be used to intubate a patient orally or nasally. It provides excellent visualization of the airway.

Proficiency in the skills required for fiberoptic intubation requires both instruction and practice.2 In most instances, it is a lack of expertise with the fiberoptic bronchoscope as well as inadequate patient preparation that results in technical problems and prevents the successful completion of fiberoptic intubation. Successful intubation is also prevented when blood and/or secretions obstruct the fiberoptic port.

A more detailed description of airway anatomy is provided in Chapters 1 and 2, on airway anatomy and basic airway management. Interested readers are referred to other sources for a more detailed description of the fiberoptic bronchoscope’s anatomy.3

The basic anatomy of the fiberoptic bronchoscope is shown in Figure 10-1. The major components are the handle, the insertion cord, and a light source. The handle contains the eyepiece for image viewing and a dial to bring the image into focus. A lever controls an angulation wire, which allows for movement of the bronchoscope’s insertion cord tip in one plane.

###### FIGURE 10-1

Anatomy of the fiberoptic intubating bronchoscope.

The bronchoscope’s insertion cord is composed of thousands of glass fibers, each approximately 10 μm in diameter, which transmit an image to a more proximal viewing lens. These fiber bundles are fragile and break easily, resulting in deterioration of the visual image; thus they should be handled with care. There is a side port that can be used for the insufflation of oxygen, instillation of local anesthetic or saline solution, limited suction (due to the small size of the port), passage of a guidewire, and end-tidal CO2 monitoring.4,5 Any fiberoptic bronchoscope used for intubation should have a length of at least 55 to 60 cm. Although fiberoptic nasopharyngoscopes have been successfully used for endotracheal intubation, they are typically unsuitable because of their short length.6,7

Fiberoptic intubation of the airway is indicated in situations where it becomes necessary to secure a patient’s airway, and an awake intubation technique is preferable to one that renders the patient unconscious. This would include patients who are at increased risk for aspiration of their gastric contents (e.g., uncertain about food intake, less than 8 hours fasting, alcohol intoxication, parturient, bowel obstruction). A fiberoptic intubation is ...

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