Fiberoptic intubations

[Jabbed]

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1. What size scope do you use for NASAL intubation? We have the standard 6.0 bronch attachment for our glidescope but its always a bear to get it through the nasopharynx. I used the slim pedi scope (2.8 mm) for a diagnostic laryngoscopy and was able to easily pass it through a lot of edema in the posterior nasopharynx. Any reason not to use this for an intubation attempt with a 6.0 tube?

2. What equipment do you use for ORAL fiberoptic intubation as adjunct? Getting around the tongue and making the turn is always tricky. I’ve done everything from having someone pull the tongue out of the mouth to have someone lifting the tongue with a VL blade while passing the scope. The thing that has been the most effective personally has been using intubating LMAs and then passing the scope through the LMA, but this is still tremendously cumbersome. Have any of you used the OPAs with a channel for the FO scope built-in (Ovassapian or Berman intubating airway)? We don’t stock them and wanted to see if anyone had used them before ordering.

 

[TooMuchResearch]

I don't understand why everyone wants to play with fiberoptic when a MAC 4 video laryngoscope with RSI just plain works.

 

[thegenius]

I don't understand why everyone wants to play with fiberoptic when a MAC 4 video laryngoscope with RSI just plain works.

agreed....499 out of 500 intubations will work just fine with VL and RSI. and knowing a couple basic airway techniques we learned in residency.
you know...fukkin simple things like cric pressure PRN, or just lifting the head off the bed. putting someone in the sniffing position.

putting someone in sniffing position is the single best thing do to prior to tubing. especially for the freedom flabby 'mericans we see daily

Anyway that doesn't answer OP's question.

 

[JacobMcCandles]

Has anyone gave you any weird looks when you use a video laryngoscope to move the tongue for your fiberoptic scope or when you use an LMA then whip out your fiberoptic scope?

 

[Jabbed]

I don't understand why everyone wants to play with fiberoptic when a MAC 4 video laryngoscope with RSI just plain works.

I mean it does until it doesn’t.

 

[Jabbed]

I just want to clarify that this is for the 1/100-200 truly anatomically difficult airway where two docs have failed, anesthesia is being paged, neck is being prepped, etc. I don’t mean to convey that I’m doing this routinely.

 

[TooMuchResearch]

If you can still ventilate that patient by other means, I would probably do that instead. If you can't, then go for neck

The last situation I was in like this, I decided it was way too risky to keep messing around trying to get anything through the normal way and could squeeze just enough air through an LMA to keep the patient alive while the neck was worked upon.

 

[Jabbed]

Has anyone gave you any weird looks when you use a video laryngoscope to move the tongue for your fiberoptic scope or when you use an LMA then whip out your fiberoptic scope?

Not really. The new glidescope models literally have a side-by-side picture so you can do just this. It’s also not uncommon to use an LMA as part of a difficult airway algorithm..

 

[hoot504]

I just want to clarify that this is for the 1/100-200 truly anatomically difficult airway where two docs have failed, anesthesia is being paged, neck is being prepped, etc. I don’t mean to convey that I’m doing this routinely.

I think you left out a zero or two on those numbers.

 

[ShockIndex]

Yes, the overwhelming majority of anatomically difficult airways can be overcome with technique and positioning. Depending on the circumstances, I may still choose to do an AFOI just so I have added layers of technique at my disposal for safety.

However, nobody has yet mentioned the physiologically difficult airway patient who is not going to hemodynamically tolerate RSI. These are a more common reason to perform an AFOI in the ED so as not to expose the patient to an induction dose of anesthetic and positive pressure ventilation that may precipitate cardiovascular collapse. The classic example is the severe RV dysfunction.

If you do not have access to flexible nasal endotracheal tubes, then I suggest that you steer away from nasotracheal intubations in general. While you can absolutely fit a 7.0 ET tube up someone’s nares, you will cause unnecessary trauma even with tubes as small as 5.0.

My recommended is that you just stick with oral AFOI for all of your anatomically or physiologically difficult airways in the ED or ICU. I use Ovassapian Intubating Airway get the scope past the oropharyngeal structures. Remember, topical anesthetic is your friend…don’t be stingy.

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[Arch Guillotti]

If you do not have access to flexible nasal endotracheal tubes

What is this? Do you mean a RAE tube?

 

[Arch Guillotti]

Any reason not to use this for an intubation attempt with a 6.0 tube?

Small scopes are more difficult to steer.

 

[Tiger26]

Having down a month of bronchoscopy during residency and bronching myself once for a lecture (at least through the cords), I think the biggest element is preparation beforehand (like many procedures) where you have everything set up and the patient optimized before moving forward with the scope.

On the rare occasion I do an awake fiberoptic, I immediately have the RT nebulize 4% lidocaine before I do almost anything else. Then, I topicalize them with lidocaine using a long, flexible atomizer tube to get down as far as possible. This and some anxiolytic intravenously is usually enough to set you up for success.

That said, I probably only need to do this every 5ish years and find that good VL technique makes fiberoptic very infrequent.

 

[ShockIndex]

What is this? Do you mean a RAE tube?

I mistyped flexible instead of angled as my brain was stuck on bronchoscopes. But I was referring to RAE or the Portex tubes. I also should have explicitly stated the caveat, “and trained in their use” since nobody should be taking on airways with unfamiliar techniques / equipment.

Regardless, my larger point was that nasal intubation in the ED or ICU should probably fall to the wayside now that EPs and intensivists are more comfortable with AFOIs using bronchoscopes which are ubiquitous in these settings. This is especially true if we are talking about the old school method of nasal intubation that was taught to paramedics and EPs 30 years ago whereby a standard ET tube is inserted into the nares to the glottis, and the provider blindly and “gently” advances the tube into the airway on inspiration with their ear next to the tube. My limited experience from many years ago is that method rarely works in a practical setting and probably cause more harm due to trauma / bleeding.