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The flexible fiberoptic bronchoscope is a useful instrument for placing endotracheal (ET) tubes in awake and nonparalyzed patients who may have contraindications to paralysis, as well as in patients undergoing rapid sequence intubation when other means of orotracheal intubation have failed. The device 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. It is most useful in performing awake intubations as it is accepted by more patients and is associated with fewer complications than awake laryngoscopy.1 Proficiency in the skills required for fiberoptic intubation requires both instruction and practice.2 Technical problems and failure to successfully intubate patients using this technique are usually due to a lack of familiarity and expertise with the fiberoptic bronchoscope, using it in the wrong clinical setting, and inadequate patient preparation.
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A more detailed description of the airway anatomy is provided in Chapters 6 (Essential Anatomy of the Airway), 7 (Basic Airway Management), and 11 (Orotracheal Intubation). A brief description of the flexible fiberoptic bronchoscope is presented in this section. There are other sources for a more in depth description of the fiberoptic bronchoscope's anatomy.3
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The basic anatomy of the flexible fiberoptic bronchoscope is shown in Figure 21-1. 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.
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The bronchoscope's insertion cord is composed of thousands of glass fibers, each approximately 10 μm in diameter. The fibers in the cord transmit an image to the proximal viewing lens. 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. Any fiberoptic bronchoscope used for intubation should have a length of at least 55 to 60 cm.4 Fiberoptic laryngoscopes or nasopharyngoscopes are usually unsuitable for intubation because of their short length.
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Fiberoptic intubation of the airway is indicated in situations where an awake intubation technique is preferable to one that renders the patient unconscious. The awake technique is indicated when it is anticipated that direct laryngoscopy might be difficult to perform or if paralysis is contraindicated.2 This would include morbidly obese patients, those having limited mandibular opening, an unstable or immobile cervical spine, macroglossia, CHF, micrognathia, patients who appear to have pathologic airway anatomy (e.g., tracheal deviation, tracheal stenosis, tumors, and trauma), and those who appear to be ...