Help With Fiberoptic intubation.

[RussianJoo]

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I am on a month where the attending that I am working with lets me try whatever airway access technique I want. So I've been attempting a few asleep fiberoptic intubations, but can't seem to get a good view and after a few minutes of trying just pop the tube in with a regular laryngoscope and move on. I've tried fiberoptic intubations 8 times thus far. My first fiberoptic intubation was a success, using the scope that we have in our main OR the rest were all failures, out of those 8 one was also a successful intubation at the VA, there the scope is attached to a big high def monitor and that fiberoptic intubation took under 1min.

The scope that we have in the main OR doesn't have a monitor attached to it, and the view in the eye piece to me seems really small. A lot of times when I look through the scope's eye piece I just see soft tissue (pink stuff), the couple of times that I've seen the epiglotis I have a really tough time directing the scope under it or I loose the view of the epiglotis really fast. A few times I thought I was in the esophagus. It was so easy to use the fiberoptic scope at the VA when I had a monitor to look at.

Any advice?? Do I just need to do it 20 times and then something will click? It's never taken me this many tries to get other procedures down and this is kind of making me frustrated.

all suggestions are appreciated.

 

[urge]

Any advice?? Do I just need to do it 20 times and then something will click? It's never taken me this many tries to get other procedures down and this is kind of making me frustrated.

Just keep trying. It will happen.

 

[Lightwand]

The way we are taught seems to be pretty effective. Do you have a mannequin you can practice on? That will help you get the mechanics down and make it much easier to troubleshoot.

Are you using an ovassapian airway? I'd recommend either using one or having someone give you some serious tongue retraction (use a 2x2 to keep the grip).

Mechanics (assuming you are R handed):
Hold eyepiece end in your R hand
Use L hand to guide scope into the mouth.
Anchor your L hand on the face to avoid molar drift.
Hold the scope right at the lips with your L hand using a pincer grasp with your thumb and index finger.
Keep the scope straight, which means using your R hand to pull back. (you will notice that you will be in an archery type position).
Pull back with your R hand, don't push forward.
Keep your L arm straight!

Four steps:
1. Scope in the mouth, curve around the tongue and advance a touch. You're not looking through the eyepiece yet (we don't have monitors for our scopes).
2. Look through the eyepiece. Ideally, your first look should be at the cords.
3. Use your L hand fingers to advance the scope a few "scootches" through the cords while manipulating the angles with your R hand.
4. Once you're through the cords and see tracheal rings, stop looking through the eyepiece. Bring the scope up over the patient (more vertical orientation) and advance your ETT. Bury it deep and pull the scope out. You can pull back until you get B breath sounds. Sucks to have it supra-glottic (I speak from experience).

If you're seeing pink, it usually means you're up against tissue. A lot of times I've found that I'm too deep and need to pull the scope back a touch to get a view. In someone with lots of redundant tissue, you can hook up O2 via the port on the scope (suction tubing fits on ours, though I guess that depends on the scope you have) and crank it up to create a jet to blow some of the tissue out of the way.

FWIW, I'm a CA-3 and I've done about 70 FOI, >20 awake and I've had good luck with this method.

Good luck! You'll get it!

 

[cincincyreds]

I find having a second pair hands that gives a good jaw thrust really helps out. A little bit of glyco before starting goes a long way.

I've been doing a lot fewer fiberoptic intubation as we now have the glidescope.

I only use the fiberoptic devices now for DLETTs and off the floor percutaneous tracheostomies.

 

[PulseOx]

Have an assistant give the patient a chin lift jaw thrust. Works every time for bad visibility. Also nasal easier

 

[epidural man]

I am on a month where the attending that I am working with lets me try whatever airway access technique I want. So I've been attempting a few asleep fiberoptic intubations, but can't seem to get a good view and after a few minutes of trying just pop the tube in with a regular laryngoscope and move on. I've tried fiberoptic intubations 8 times thus far. My first fiberoptic intubation was a success, using the scope that we have in our main OR the rest were all failures, out of those 8 one was also a successful intubation at the VA, there the scope is attached to a big high def monitor and that fiberoptic intubation took under 1min.

The scope that we have in the main OR doesn't have a monitor attached to it, and the view in the eye piece to me seems really small. A lot of times when I look through the scope's eye piece I just see soft tissue (pink stuff), the couple of times that I've seen the epiglotis I have a really tough time directing the scope under it or I loose the view of the epiglotis really fast. A few times I thought I was in the esophagus. It was so easy to use the fiberoptic scope at the VA when I had a monitor to look at.

Any advice?? Do I just need to do it 20 times and then something will click? It's never taken me this many tries to get other procedures down and this is kind of making me frustrated.

all suggestions are appreciated.

45 to 50 is what I have heard quoted before you are proficient. Keep practicing.

Get better with using the equipment. Get that piece that allows you to scope a patient will still maintaining positive pressure and do some bronchs on your intubated patients. This will help you with your scope skills. And it isn't unethical....and if some of ya all think it is, what is the TEXTBOOK answer to the only way to definitely verify tube position?

 

[narcusprince]

Hey Russian
Got a strategy. Next time have the glidescope and use the glidescope as a conduit with your attending directing you. Do not look at the screen on the glidescope thats cheating but he can better guide you to how to maneuver into the airway. As an attending in a short couple of days 160's to count I will teach my residents to do fiber optics this way.
NP

 

[BLADEMDA]

Hey Russian
Got a strategy. Next time have the glidescope and use the glidescope as a conduit with your attending directing you. Do not look at the screen on the glidescope thats cheating but he can better guide you to how to maneuver into the airway. As an attending in a short couple of days 160's to count I will teach my residents to do fiber optics this way.
NP

I do it that way all the time. It works great and I use the glidescope screen.

 

[deleted9493]

Intubating oral airways are insanely helpful--they'll get you behind the tongue without mucking up your view. When coming to the end of the airway device with the scope, ask your attending to give a little jaw thrust--as has been previously mentioned. Things should open right up.

 

[rsgillmd]

Standard prep: well oxygenated, glyco to reduce secretions

Use an airway device to assist you: Ovassapian, the pink airways (the name is slipping me now), or whatever else you have in your institution.

Jaw thrust from an assistant

Pink = tissue. Usually you are too deep, but not necessarily. Just back up slowly.

Slow deliberate movements, especially when working with the thinner scopes (ex: infant). Small movements at the surface translate to large movements on the screen.

Assuming you are going oral: initially, don't even look at the screen. Look in the mouth. As soon as your tip is at the base of the tongue, making the curve, press the lever down to look up with the scope. Now look through the scope. Usually you'll be staring at epiglottis.

Practice, then practice some more, and then practice some more. I started off struggling also. During a rotation at an affiliated hospital at the beginning of my CA-2 year the chairman/director asked me what I wanted to get out of the rotation. I told him fiberoptic intubations. We did a lot of them, at least one per day, sometimes more. By the end of the month I was much more comfortable.

The eyepiece is annoying, especially on the Olympus scopes, but the view is just a smaller version of what you are going to see on the television screen. Because you can look at a screen with both eyes, a fiberoptic intubation is going to always be easier/faster on a screen. However, the principles don't change.

Hang in there.

 

[RussianJoo]

So, I finally got my 3rd Fiberoptic intubation today. We had the glide scope on stand-by because the lady was a pretty poor airway MP:IV with poor mouth opening, fat neck, and no chin. Somehow I got it pretty much right away, the pt didn't de-oxyginate or anything. Stuck the scope in, looked through the eye piece and saw cords, went through, didn't think I was through for a second but then saw tracheal rings, advanced down to right above the carina, and dropped the ET tube in.


What I realised after today, I might have seen cords before on previous attempts, but because sometimes I don't see the white of the cords I don't think it's the tracheal opening. This happened today, I saw cords but then a second later didn't, and just saw the opening i.e.black (probably because I changed the angle of the scope?) Also once through the cords I had to advance a little more to start seeing rings, so I might have been in, in the past but because I didn't advance far enough to see rings I thought I was in the esophagus and pulled the scope out.

So yeah I just need more practice, and it looks really weird looking through the eye piece while going through the cords, because I am not seeing the scope go through the cords from the outside but actually looking through the scope. Something I need to get used to.


My attendings give me jaw thrusts, we use an airway in which the scope goes through (white plastic and wider and flatter than a regular oral airway). So they are doing everything they can to help me out.

The Glidescope idea is great and something I'll consider in the future.

Also what I did differently today was use a step or "lift" to get higher above the pt, that way it's easier for me to keep my hand extended and the scope straight that way it's easier to manuvar the scope.

Thanks everyone for your help and suggestions. Hopefully I can get around 30 fiberoptic intubations this month. We intubate for fast breast cases so I should be able to get acouple a day.

 

[deleted126335]

I never found asleep fiberoptic intubation to be a particularly useful skill. Nor have I ever found it to be helpful in getting comfortable with the scope. If I have an unanticipated difficult intubation/easy to ventilate, by the time someone calls for the scope 3 or more laryngoscopies have been done, the airway is probably soiled with saliva and blood making fiberoptic scope conditions crappy. Yes I have cheated by having an assistant use a mac blade or a glide scope and then with their hand put the scope close to where it should go and then intubating, but that is not a skill that needs much to master. I actually believe that teaching residents is easier on awake patients as the tissues do not collapse. The key skill is learning to topicalize properly with light sedation

For those that have never been I highly recommend the difficult airway course, www.theairwaysite.com

 

[fakin' the funk]

1. You need a good assistant.
2. Above recommendations for Ovassapian and pink (Williams) airways are good ones. The only pitfall is if it is TOO deep and you miss epiglottis/glottis entirely.
3. I prefer no oral airway myself. The key, then, is STAY MIDLINE. Are you in midline? No? Get back to midline then!

But most importantly, as others have said,
4. JAW THRUST! Or tongue retraction! Absolutely key. If you have neither, you can still scoot your scope between posterior pharynx and tongue base (it's that horizontal line between two seas of pink tissue) and end up at epiglottis.

 

[granolabar2]

de-fogging solution for the fiberoptic tip (they have this for the endoscopy equipment if the anesthesia techs don't have it)

 

[RussianJoo]

cool, thanks guys... got 3 more in a row on fairly tough airways MP IV with poor mouth openings, and huge necks. Seems like I just needed to do a few more to get the hang of it and was concerned prematurely.