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.
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
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 ...