Fibreoptic assisted airway management

Dr Arvind Kumar, Dr Bijaya K. Shadangi, Dr Shashidhar TB

consultants ,Medanta-The Medicity. Gurgaon,New Delhi.
[email protected]

Introduction

Inability to ventilate and intubate a patient still remains an important cause of morbidity and mortality peri-
operatively. In new era of anaesthesia, flexible fiber optic has become an essential asset to tackle difficult
airway and endotracheal intubation in routine as well as in emergency situations. Flexible fiberoptic is
very useful for anaesthesiologists in the management of difficult tracheal intubations, evaluation of upper
airway, verification of endotracheal tube placement, repositioning or checking patency of endotracheal
tubes, changing endotracheal tubes, placement of double lumen tubes and placement of endobronchial
blockers.

By definition, fibre optic is a transparent, flexible fiber made of glass (silica) or plastic. Its function is to
transmit the light from one end to another. These fibers are usually wrapped in bundles so it can transmit
image from distal end to proximal end, thus confined spaces can be seen. Precisely, fibreoptic is an
instrument which transmits the image from distal end lens to the proximal end lens through illuminated
fibres.

History

The history of fiber-optic evolvement is almost two century old. Principle by which light can be guided
through refraction was given by Daniel Colladon and Jacques Babinet in Paris in early 1840s.

Demonstration that light used internal reflection in fibre-optic was done by Jhon Tyndall in 1870, using jet
of water that flowed from one container to another.

In 1880, William Wheeler, invented a system of light pipe lined with highly reflective coating, which later
became a cornerstone of modern fibre optic.

In 1888, Dr Roth and Prof. Reuss demonstrated body cavity illumination by bend glass rod through
source of light and proposed use of fiberoptic to visualize the body cavity through fibre- optic system.

The first rigid bronchoscopy for removing foreign body, pork bone, was done in 1897 by Gustav Killian. In
1898, David Smith from America applied for a patent on bent glass rod device for surgical lamp. In 1930,
Heinrich Lamm, a German medical student, assembled a bundle of optical fibres to carry an image.

Real success came in 1950s when Brian O’Brien at American optical company, made first fibre scope
and Nrinder Kapany who first coin the term fibre-optic in 1956 at London. First fibre optic endoscope was
invented by Fernando Alves Martins of Portugals in 1963-64. In 1966, Shigeto Ikeda from Japan invented
first fibre optic flexible bronchoscope.

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 Fiberoptic assisted airway management

In 1967, Dr P Murphy was the first to use a fiberoptic instruments for the control of airway when he
performed a nasal intubation under general anaesthesia for a patient with advanced Still’s disease uing
choledoscope. In 1972, Stiles and colleagues reported use of FOI in 100 patients.

Principle of fiberoptic devices

The difference in the speed of light in different media affects the direction of light when light travels from a
medium to another medium with different refractive index. This phenomenon of change in the path of light
travelling from one media to other media is called
refraction

The effect of each substance on light velocity is

indicated by the refractive index of the substance.
Index of refraction (µ) is calculated by dividing the
speed of light in a vacuum (c) by the speed of light in
some other medium (v). It also measure of the bending
of a ray of light when passing from one medium into
another.

Light travels at different speed in different substances,

with maximum velocity in vacuum (300,000 kilometers
per second). When a light travels from optically lighter
medium to denser medium, the light rays will bend
towards normal and vice- versa. So, when light will
travel from water (optically dense) to air (optically light), the light rays will be deflected away from normal
as depicted in following photographs:

Here, as the angle of incidence increases, angle of refraction also

increase -- more and more of the light is reflected back from the
surface. For some angle of incidence, all of the light is
reflected and none of it passes into the air. This angle is called as
Critical angle for that interface of media and the phenomenon is
called total internal reflection.

An Optical Fiber works on the principle of Total Internal

Reflection.
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Instrument details
The fiberoptic scope is a flexible instrument, capable of transmitting an image from distal end to the
proximal end. It has bundle of glass fibers capable of total internal reflection of light. A typical bundle
contains 10000 glass fibers, each having diameter of 8-
10 micron.
The optic fiber consists of a core surrounded by a
cladding layer and to protect the cladding there is
coating.

The total internal reflection effect is used in optical

fibers to confine light in the core. Light travelling in
optically dense core (µ= 1.62) of fiber hits the boundary
of optically lighter cladding (µ= 1.52) at steep angle
(larger than critical angle for the boundary) light rays
are completely reflected and guided down the length of
an optical fiber.

Because the light must strike the boundary with an angle greater than the critical angle, only light that
enters the fiber within a certain range of angles can travel down the fiber without leaking out. This range
of angles is called the acceptance cone of the fiber. The size of this acceptance cone is a function of the
refractive index difference
between the fiber's core and
cladding. In simpler terms,
there is a maximum angle
from the fiber axis at which
light may enter the fiber so
that it will propagate, or travel,
in the core of the fiber. The
fibres are made such, so that
maximum light can reflect
internally with the help of
cladding and light travels
throughout the length.

A single fiber is capable of transmitting the light but is incapable of transmitting an image. To solve the
problem of image transmission, an objective lens is placed at the tip of the fiberscope. This lens focuses
the image on a large number of flexible fibers, which are tightly fastened together at the proximal and
distal ends of the scope. The fixed, flexible bundle has the identical arrangement of fibers at both ends of
the scope, which permits the insertion cord to be flexible and allows the image to be transmitted through
the length of the scope without distortion. Without this organized, coherent bundle and the optical
insulation of each fiber, an image could not be transmitted.

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 Fiberoptic assisted airway management

Other group of fiberoptic bundles transmits light from an external light source to the distal end of scope to
light the endoscopy field during the endoscopy procedure. Since these bundle are not required to transmit
image, so they are not arranged in a coherent bundle.
In order to prevent degradation of the image, each fiber is coated with a transparent substance of lower
refractive index (cladding). The cladding aids in light transmission as well as optical insulation of each
fiber. Following figure shows parts of fiberscope:

The flexible fibre optic consists of three parts:

a) Body / main controls: it consists – Control lever
- Eye piece and diopter ring
- Working channel port

b) Insertion cord/ shaft: it consists - Image transmission bundle

- Light transmission bundle

- Working channel

- Angulation wires and distal bending section

c) Universal light cord

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Body/ main controls:

The body is shaped thick, cylindrical/quadrangular/round so that it can be hold comfortably in the palm of
either hand.

Control section: It has an angulation control (AC) lever which can be moved upward and downward.
The connector between insertion cord and the body is of conical shape, which helps in mounting over the
distal end of endotracheal tube. Control lever allows thumb to move tip vertically by activating angulation
wires in the insertion cord. Up and down movement of control lever moves the tip posterior and anterior
respectively.

The eyepiece consists of multiple lenses which collects composite image from the transmitted image of
fibreoptic bundle. The dioptric adjusting ring can be rotated over the body to focus the sharp image on the
retina of operator. While viewing in the eyepiece, operator sees a pointer which indicates the anterior
direction of the distal tip.

The working channel port has suction connector with valve that is covered by a rubber cap. The suction
channel port traverses till the distal end, which can be used for suction, instillation of drugs, oxygen
supplementation and insertion of wires for anterograde and retrograde fibreoptic intubation. Depending on
the model, the working cannel may be as small as 1.2mm. So, it may become clogged easily when used
for suctioning blood and secretion. Inflation of oxygen through this port blows secretion away from the tip
of scope and dries the tip resulting in better visualization of the structures. The suction valve is loaded
with spring, which when pressing by index finger, activates the suction.

Insertion cord /shaft

Insertion cord goes into the trachea and acts as guide for railroading the endotracheal tube. The inner
diameter endotracheal tube should be 1mm or more than the outer diameter of insertion cord. Because of
60 cm length, it allows the operator to railroad the tube after placement of tip in the trachea. White
marking indicates 5 cm distance from 15 to 40cm.

Approximately 6000 image transmission fibres are bundled together tightly with other component. So that
along with flexibility to facilitate the railroading, cord remains stiff enough.

One or two light transmission bundles caries light from light source to the field of vision. The working
channel extends from the working channel port to the tip of distal end. It is wrapped with plastic to prevent
fluid entering the fibreoptic bundles.

Angulation wires are two separate wires that travel from the control lever to the tip of distal end. The distal
bending section to accommodate the tip and is most flexible section of fiberscope. The upward or
superior deflection ranges from 120° to 180°, whereas the downward or inferior deflection varies from 60°
to 130°. The field of view ranges from 70° to 120°.

Universal light cord:

It serves as a transmission of light from light source to the distal end of tip. It has a cap at proximal end
which should be capped during transportation and sterilization.

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Light source:

Light source is a bulky part of the instrument. The light cord of fiberoptic is connected into the light
source. These are the smaller halogen light source and 150w of power. These days lithium batteries are
also available which replace the light guide cable and can last upto 60 min. This makes fiberscope more
easy is to carry from one place to another.

Sizes of fiberscope for adults and paediatric patients:

The external diameter of flexible bronchoscopes ranges from 0.5 mm (ultrathin) to 6.3 mm. The diameter
of the working channel measures from 1.2 to 3.2 mm. The length (usable length) of the insertion cord
varies from 200 to 600 mm (20-60cm). Ideally the outer diameter of a bronchoscope should be 1mm or
less then of internal diameter of endotracheal tube. Normally, fiberscope with outer diameter 5.2 or less is
used with endotracheal tube size from 7.5 mm OD to 8.5 mm OD (outer diameter).
Tabular presentation (table 1) shows the different sizes of LMA which can accommodate the largest size
of endotracheal tube (internal diameter in mm) and further, largest size of fiberscope which can go to the
respective endotracheal tube.

Table 1 – Laryngeal Mask Airway (LMA) as a Conduit for Tracheal Intubation with a
Fiberoptic Bronchoscope (FOB)

LMA Size Largest ETT ID (mm) Largest FOB Inside the ETT: Compatible FOB Models (with OD in
OD (mm) mm)
1 3.0 uncuffed 2.2 Olympus LF-P (2.2)
1.5 4.0 uncuffed 3.0 Olympus LF-P (2.2)
Pentax FI-9BS/RBS (3.0)
3.5 cuffed 2.4 Pentax FI-7P/BS/RBS (2.4)
2 4.5 uncuffed 3.4 Olympus LF-DP (3.1)
Pentax FI-10BS/RBS (3.4)
4.0 cuffed 3.0 Olympus LF-P (2.2)
Pentax FI-9BS/RBS (3.0)
2.5 5.0 uncuffed 4.0 Olympus LF-2 (4.0)
Pentax FI-10BS/RBS (3.4)
4.5 cuffed 3.4 Olympus LF-DP (3.1)
Pentax FI-10P2/BS/RBS (3.4)
3 5.5 cuffed 4.2 Olympus LF-2/GP (4.0/4.1)
Pentax FI-13P/BS/RBS (4.2/4.1/4.1)
4 5.5 cuffed 4.2 Olympus LF-2/GP (4.0/4.1)
Pentax FI-13P/BS/RBS (4.2/4.1/4.1)
5 6.5 cuffed 5.2 Olympus LF-TP (5.2)
Pentax FI-16BS/RBS (5.1)
ETT, endotracheal tube; ID, internal diameter; OD, outside diameter.

Table 2 shows different sizes of double lumen tube (DLT) that can accommodate largest size of fiberoptic
bronchoscope (FOB).
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 Fiberoptic assisted airway management

Table 2-Largest size of bronchoscope which can be accommodated in different sizes

of Double Luman Tube(DLT)
Size of DLT (Fr.) Internal Diameter (mm.) Compatible FOB Models (with OD in
mm)
26 4.0 Olympus LF-2 (4.0)
Pentax FI-10BS/RBS (3.4)

28 4.5 Pentax FI-13P/BS/RBS (4.2/4.1/4.1)

Olympus LF-2/GP (4.0/4.1)
35 5.0 Olympus LF-2/GP (4.0/4.1)
Pentax FI-13P/BS/RBS (4.2/4.1/4.1)
37 5.5 Olympus LF-TP (5.2)
Pentax FI-16BS/RBS (5.1)
39 6.0 Olympus LF-TP (5.2)
Pentax FI-16BS/RBS (5.1)
41 6.5 Olympus LF-TP (5.2)
Pentax FI-16BS/RBS (5.1)

Current Uses of FOB:

 Nasal and oral intubation
 Evaluation of airway
 Verification of accurate placement of single or double lumen endotracheal tube and LMA
 Endotracheal tube exchange
 Placement of bronchial blocker devices
 Removal of secretions and mucus plugs

INDICATIONS:
 History of difficult intubation
 Suspected difficult airway based upon findings in history or physical exam, including but not
limited to the following:
- Trauma to the airway - History of radiation to the airway
- Deep neck infections - Severe ankylosing spondylitis
- Tumors of the larynx or pharynx - Acromegaly
- Congenital airway abnormality, such as Treacher-Collins or Pierre Robin Syndromes
- Inability to access the cricothyroid membrane, in case emergency surgical airway is
required
- Morbid obesity and history of sleep apnea with suspected difficult airway requiring
intubation
- Anatomy that otherwise predisposes patient to difficult intubation and difficult mask
ventilation while asleep
 High risk for aspiration of gastric contents
 Need for neurological exam immediately following intubation
- Cervical spine instability due to trauma or degenerative disease
- Vertebrobasilar artery insufficiency
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CONTRAINDICATIONS
Absolute contraindications
 Patient refusal
 Pharyngeal abscess
 Limited space around FOB eg. Edema of pharynx
 Allergy to both ester and amide classes of local anesthetics
Relative contraindications may be overlooked in the true emergency situation because the risk of the
procedure is less than the risk of hypoxemia or impending loss of the airway:
 Infection at sites of local anesthetic injection/application
 Raised intracranial pressure (ICP) that might be exacerbated by coughing
 Penetrating eye trauma that might be exacerbated by coughing

Advantages:
 Excellent visualization of the airway
 Minimal hemodynamic stress when properly performed
 Oral or nasal intubation is possible in the adequately prepared patient
 Ability to apply topical anesthesia and insufflate oxygen during intubation

Disadvantages:
 Expensive
 Requires careful maintenance
 Presence of blood/secretions impairs visualization
 Requires practiced expertise for use in acute situations

EQUIPMENT/ DRUGS REQUIRED

There should be pre- operative check list of instruments before starting fiberoptic bronchoscopy.
Those are as follows:
 Flexible fiberoptic bronchoscope and light source
 Suction (functional)
 Oxygen source (two; one anaesthesia
machine, second from direct cylinder)
 Cuffed endotracheal tubes (in several
appropriate sizes)
 Warm solution, such as saline surgical
irrigation, in a 1-L bottle
 Lubricant, such as silicon gel or liquid
paraffin
 Antifog liquid drops for the fiberoptic
camera lens
 Tongue depressor or laryngoscope blade

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 Fiberoptic assisted airway management

 Nasal trumpet with 7.0 ETT connector inserted in proximal end

 An antisialagogue, such as glycopyrrolate (0.2 to 0.4 mg in adult patients)
 Local anesthetic jelly, such as lidocaine (viscous 2%, 4%, and 5% paste)
 10% lidocaine topical spray
 Phenylephrine (10 mg/mL)
 Sedative hypnotics, such as benzodiazepines or low-dose propofol infusions together with an
opiate delivered in small doses (fentanyl or remifentanil), with or without droperidol (not to exceed
2.5 mg in adult patients)
 Right-angle forceps
 Cotton soaked pledgets
 Williams or Berman intubating oral airway
 Appropriate vital signs monitor (ASA Standard Monitoring)

Technique of fiberoptic intubation:

Intubation with the help of fiberoptic bronchoscope should be done by an operator who has previous
hands- on experience on mannequins or in presence of an expert.
Some consideration before proceeding with FOB:
1. Whether to keep the patient awake until the control of airway is established or to
perform the technique with the patient anaesthetized.
Choice for fiberoptic intubation with the patient anesthetized (with muscle relaxant or without muscle
relaxant) or awake can be made on ability to ventilate the anesthetized patient, need to evaluate the
awake patient after intubation. The conditions where there are chances of difficult mask ventilation,
laryngoscopy nd intubation, awake fiberoptic intubation should be preferred.
2. Whether to use nasal or oral route for FOB.
In general, nasal route is easier than oral for FOB because the angle of curvature of ETT naturally
approximates that of patient’s airway. Gag reflex is less pronounced with nasal route, but bleeding is
more if nasal route is used.
Anesthetized nasal approach is indicated in patients having surgery in their oral cavity.
Optimize position of operator and patient:
For optimization of position table should be as low as possible. Head should be in neutral position and if
patient’s condition allows he/she be in supine
position. But condition like respiratory distress,
operator my need to make sitting position and in this
situation fibreoptic is done by facing the patient, after
inverting the FOB view.
Holding the FOB correctly:
rd th
The FOB is held in the palm of left hand with 3 , 4 ,
th
5 fingers holding the proximal scope. The left index
finger tip rests near the suction port to activate the
suction channel when required. The left thumb is
flexed on the AC lever. The distal end of scope is
held by right hand in pen holding fashion with the little

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 Fiberoptic assisted airway management

finger of the right hand resting on patient’s face to stabilize the cord.

The insertion cord is held straight and taut at all the times. Failure to do so may result in easy operator’s
fatigue as well as a loose cord that will not transmit the rotation movement of the body of FOB to tip of
FOB.
Manipulating the tip of FOB:
There are three ways in which an operator can manipulate the tip of FOB towards the desired target.
1. Advancement (or withdrawal) of whole FOB moves it towards the target.
2. Tip deflection: When the AC lever is pressed downward, tip of the insertion cord is flexed upward
(anteriorly), and when AC lever is pressed upwards, the tip moves downwards (posteriorly).
3. Rotation: the sideways movements of the tip are achieved by rotation of the body of FOB towards the
target while maintaining tip deflection.
0
Therefore, by meticulously combining these movements of tip, it is possible to visualize 360 .
Orientation Marker: When viewed in the eyepiece or on the monitor, an orientation marker (triangular
mark) is usually seen at 12 o’clock position which indicates the anterior direction, while 6 o’clock indicates
posterior direction.

Patient preparation:
Patient counseling regarding details of the procedure, need of patient’s co-operation for airway block and
fiberscopy in awake procedure are vital for successful fiberoptic intubation. Informed consent for the
same should be taken.
Depending on the technique (awake versus GA), patient and trolley should be prepared.
A knowledgeable person should be ready beforehand, atleast be able to do bag & mask ventilation. A
secured iv cannula and all vital monitoring should be attached before the procedure.

Pre medication:
 Antisialogogue: such as glcopyrrolate 0.01mg/kg intramuscularly or intravenously should be given 20
minutes before the procedure. It helps in drying the secretion and hence operator gets clear field of vision
during the procedure.

 Sedation:
Whether sedation is to be given or not depends on the patient’s anxiety level , difficulty of anticipated
airway and awake versus general anesthesia fiberscopy technique.
Choices could be midazolam, fentanyl, dexmedetomidine, ketamine, remifentanyl.
Goal should be respiratory rate >9/min. Spo2≥92%. Patient cooperation is must in awake fiberoptic
intubation.

Table 3: Commonly Used Medications and Dosages with Their Reversal Agents

Medication Dosage and Route Effect Reversal Agent

Atropine 0.5–1 mg IV, IM Antisialogogue N/A

Glycopyrrolate 0.2–0.4 mg IV, IM Antisialogogue N/A

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 Fiberoptic assisted airway management

Dexmedetomidine Loading dose: 1 mcg/kg/min

over 10 min
Infusion: 0.2–0.7 mcg/kg/min Sedative N/A
Midazolam 0.5–4 mg IV Sedative Flumazenil
Fentanyl 10–100 mcg IV Opioid Naloxone
Alfentanil 100–1000 mcg IV Opioid Naloxone

Key anatomic structures encountered in orotracheal fiberoptic intubation are:

1. Nose 2. Front teeth 3. Tongue 4. Hard Palate
5. Soft Palate 6. Uvula 7. Tonsillar Pillars 8. Base of Tongue
9. Valecula 10. Epiglottis 11. Arytenoids(and posterior commissue)
12. Vocal Cords 13. Trachea 14. Carina

Key anatomic structures in trans-nasal fiberoptic intubation:

1. Nares 2. Nasal septum 3. Turbinates
4. Adenoids 5. Base of Tongue 6. Valecula
7. Epiglottis 8. Arytenoids 9. Vocal Cords
10. Trachea 11. Carina

Awake Oral fiberoptic intubation:

The patient should be prepared well by giving premedication and airway blocks, and its effect checked.
The tip of FOB should be cleaned, focused and defogged before use. Lubricate the insertion cord taking
care not to smear any jelly on the tip of scope. After that, place the lubricated ETT high on insertion cord.
ETT can be taped on the conical connector for convenience.

Protect the instrument from the patient’s teeth by using bite block. If patient still have gag reflex, LA
supplementation with or without i/v sedation can be done. Attach the suction to FOB. The insertion cord
should be kept straight during the procedure even if stepstool is needed.

Always keep the FOB in midline. Keep the tongue from falling backwards. Awake patient can be
asked to protrude out his tongue which then can be held between a gauze piece by an assistant.
Advance FOB very slowly, while keeping recognized object in the middle of the view; use lever to look
up/down, turn BOTH hands use lever to look sideways. Dominant hand should have very gentle & slow
movement keeping black notch at 12 o’clock position.

Avoid shear force, pink out or getting lost. If airway is reacting to tip, ask assistant to inject 0.5-1ml of LA
fast via FOB port. Find vocal cord and then carina. Hold FOB immobile, then insert ETT facing bevel
posteriorly or anteriorly (less preferred). When ETT is reached near vocal cord, ask patient to inhale
deeply and insert the ETT quickly, until 2-3 cm above carina under vision. Stabilize the ETT, inflate the
cuff and remove the FOB.

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Awake Nasal fiberoptic intubation:

Before starting, nasal decongestant and lidocaine jelly should be applied to both nostrils. Insertion of tip
till 0.5 to 1cm into nostril can be done without looking through the FOB. One can see nasal septum on
one side and inferior turbinate on the other side and hard palate on the top.

The insertion cord of FOB is not so strong to lift away or part the tissue away it encounters; therefore, it is
essential to have an air space at the end of tip of scope as it is advanced further down. This air space is
seen as black area. The tip of FOB must follow this black column of air.
When we reach posterior pharyngeal wall, we may see the posterior pharyngeal wall below and soft
palate above. This view may get obscured by secretions which can be sucked away or blown away by
attaching O2.

Then we enter oropharynx, where we can see soft palate and uvula above and posterior pharyngeal wall
below. Vision may be lost at this point due to apposition of uvula and soft palate with posterior pharyngeal
wall. Patient can be asked to protrude out his tongue in order to open air space and epiglottis may
suddenly come into view.

The epiglottis may appear very large. One must spray local anesthetic drug on epiglottis before
proceeding further. Vision may be lost again at this point. Ask the patient to take deep breaths or protrude
out his tongue or phonate, which will help to lift away the epiglottis from the posterior pharyngeal wall.
Sometimes tip of scope may deviate laterally right or left and enter either the pyriform fossa below or the
vallecuale above. In both circumstances, monitor will show uniform red color only. One need to withdraw
the FOB till one is able to identify the structure and re-advance the FOB in correct direction.

Once the epiglottis is seen, tip of FOB is passed underneath the epiglottis and then turned upwards until
vocal cord is seen. Vocal cord never stops moving. Instill some LA and they will appear less active. Ask
the patient to take deep breath and FOB is passed between vocal cords. Tracheal rings and tracheal
lumen becomes visible, instill some LA and advance FOB till carina.

Keep the FOB in neutral position and railroad the ETT over FOB into trachea. If tube cannot be advanced
smoothly (as it may impinge on vocal cord or right arytenoids), then withdraw ETT by 1 to 2 cm, rotate it
0
anticlock wise through 90 and re-advance. Once the tip of the tube is correctly positioned, withdraw the
FOB remembering to keep its tip in neutral position.
Again reconfirm the position of ETT by auscultation, capnograph waveform.
Massive facial trauma is contraindication for nasal fiberoptic & major airway bleed is contraindicated in
both types of fiberoptic intubation.

FOB under Anaesthesia (with or without muscle relaxant)

Main difference between awake patient and anesthetized patient is the loss of muscle tone and soft
tissues of the pharynx tend to relax and limit the visualization with the FOB. Following methods can be
used to generate requisite space for FOB:
1. Using jaw thrust or tonsil retractor
2. Expanding the ETT cuff in the pharynx
3. Applying traction on the tongue.

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Awake intubation GA without muscle relaxant GA with muscle relaxant

Spontaneous breathing patient, Spontaneous breathing present, Loss of spontaneous breathing, may be
oxygenation maintained, sufficient time maintaining oxygenation and troublesome in difficult airway patient
for FOB anesthesia

Adequate LA/ block needed to prevent Easier to maintain adequate depth of Depth can be easily maintained with IV agents.
patient reflexes, discomfort, anesthesia
laryngospasm

No soft tissue collapse, better view. Less soft tissue collapse, better view Complete loss of soft tissue tone, difficulty in
FOB view

Patient is safe If FOB fails, we can awake patient We can have ‘cannot ventilate, cannot
safely intubate’ situation

Problems during FOB

1. Poor vision or disorientation of field:
- It is a frequent problem for the beginners/ Inexperience
- Poorly focused eyepiece
- Film over lens
- Fogging
- Secretion and blood
- Touching the mucosa (red out/ pink out)
- View may be seen upside down. Pointer in the view indicates anterior part of the field. Before
inserting the cord one must focus the fibrotic by seeing some digital number or text for clear &
crisp image.
- Unable to see: one must ensure a good brightness of light from light source. The ambience is
kept relatively darker to get the optimum view. Sometime cleaning the secretion or blood from the
distal tip becomes necessary if the field cannot be seen. If there is any secretion, one must keep
suctioning as the cord travels through the air passage. If the field is lost, always withdraw the
distal tip to half a centimeter then try to look the passage and rotate tip accordingly.
2. Bleeding may occur from nostril, oral cavity or trachea. This is usually a very minor bleeding which
stops by itself. Active intervention is not often required. For nasal bleeding, epinephrine soaked cotton
can be used.
3. Coughing
4. Desaturation
- Respiratory depression due to drugs
- Prolong apnea under anesthesia
- Excessive use of suction
- Endobronchial intubation
- Loss of airway
- Increased airway resistant in awake, spontaneously breathing patients.
- Solution: Oxygenation through nasal prongs in both the nostril can during oral fiberoptic or in
opposite nostril during nasal fiberoptic can be used. Alternatively, O2 can be connected into the
broncoscope. It also helps to see clearly in the field by spreading away the secretion. Another
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way to supplement the O2 is to ask the assistant to hold the breathing circuit (without mask) near
mouth or nostril.

5. Laryngospasm and bronchospasm

6. Esophageal intubation
7. Failure to railroad the endotracheal tube (hang up)
- Use the nasal approach
- Use the correct size ETT (not too large not too small)
- If hang- up occurs- pull back & twist the ETT and do some external manipulations.
- The scope’s convex lens means that even though you may see the target, if it is not in the middle
of the image, advancing the scope will NOT take you to the target.
8. ‘Pink out’ or ‘lost in space’
- Failure to keep the scope in the midline
- Failure to recognize anatomy
- Failure to use anatomic maneuvers- tongue retraction, and jaw lift for maximizing anatomic
exposure.
- Withdraw FOB and redirect to previously recognized structure.
9. Tachycardia & Dysarrhythmia: This is quite common in apprehensive or cardiac patients. One must
ensure adequate sedation before starting bronchoscopy. In cardiac patients, cardiac drugs like beta
blocker should be continued till the day of procedure. Some anesthetists prefer intravenous clonidine 50-
150 mcg for premedication. It solves both the purpose sedation & control the heart rate. Very rarely
antiarrhythmic agent is required.

Complications
Common
- Gagging - Epistaxis
Infrequent
- Oversedation (with loss of spontaneous ventilation)
- Inability to pass endotracheal tube
- Laryngospasm
- Hematoma (if invasive blocks have been performed)
- Infection (if invasive blocks have been performed)
- Dysphagia - Dysphonia
- Inadequate sedation with unpleasant recall by the patient
Serious, rare complications
- Local anesthetic toxicity
- Damage to vocal cords
- Vomiting (aspiration)
- Traumatic pharyngeal or laryngeal injury
- Bacteremia
o More common after nasal intubation
o In patients with valvular heart disease, prophylactic antibiotic administration before nasal
but not oral intubation is recommended

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 Fiberoptic assisted airway management

Cleaning, Disinfection and sterilisation

Immediately after the use, suction channel should be rinsed with water or saline to remove blood, tissue
or secretion. Wiping of the outside o the bronchoscope and brushing of all channels with a detergent
solution should be done immediately. The removed and disassembled suction valve should be cleaned
with a brush and detergent solution & dried. Almost 99.9% of organism can be removed with soapy tepid
water. Additional items of equipments like camera, remote video controllers, light sources, and procedure
carts should be regularly wiped with 70% alcohol.

When liquid chemicals such as glutaraldehyde, peracetic acid, or hydrogen peroxide are used, the items
must be meticulously cleaned with soap and water and thoroughly dried before being placed into the
solution. For high level disinfection, the items must be soaked for at least 20 minutes (12 minutes for
Cidex OPA®) or for 10 hours for sterility. Two percent alkaline glutaraldehyde is the disinfectant of choice
for FOB. This is considered sufficient to kill virtually all pathogens surviving on a well cleaned
bronchoscope. Following the use of these chemicals, all instruments must be rinsed with sterile water or
normal saline three times to remove any chemical residue. To rinse disinfected endoscopes and
bronchoscopes, use water of the highest quality practical for the system’s engineering and design (e.g.,
sterile water or bacteriologically-filtered water [water filtered through 0.1–0.2-μm filters]).

FOB is damaged by conventional heat sterilization. Gas sterilization with ethylene oxide at temperature
0
less than 55 C followed by 10- 12 hours of aeration time is safe but is not always practical.

Handling:
Flexible fiberscopes are fragile and expensive equipment, so extra precaution must be taken. During use,
extra force should not be used to insert or to bend otherwise it may damage the fibers. A bite block
should be used in an awake patient. FOB should never be flexed forcibly because it can break the
fiberoptic bundles and hence decrease the amount of light that reaches the tip of scope. Breaking of
fibers results in black spots in the image as those pixels of data are lost. Cary case should be used to
transport the scope. There should be dedicated cupboard so that the cord stays straight. One designated
anaesthesia nurse should be appointed for general maintenance of fibroptic.

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 Fiberoptic assisted airway management

Other relevant information related to fiberoptic intubation

Fiberoptic- Compatible Oral Airways are available. It can be used during fiberoptic bronchoscopy to ease
the manipulation & intubation. These airways are made anatomically oriented.

Patil-Syracuse: It is made up of aluminium & has

lateral passage for suctioning. Airway must be
removed before insertion of the tracheal tube.

William’s airway intubator:

Anterior Tracheal tube is inserted directly through

its orifice. Airway is removed by slipping it over the
tracheal tube.

Ovassapia: Posterior channel may limit access to

“anterior” airways. Channel is absent near the tip.
Localization of the midline may be difficult.

Luomanen: Similar to Ovassapian but with a deep posterior channel that continues to the tip.
Access to glottic openings that are off-midline may be difficult.

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 Fiberoptic assisted airway management

Berman intubating/pharyngeal airway:

Posterior Lateral slit allows for removal from around

the tracheal tube. However,this may pose some
difficulty.

Optical fiberoptic stylets:

Optical fiberoptic stylets have a rigid body

with flexible tip. It has malleable lighted
stylets. Less skill is required to learn
intubation with the help of optical stylets & it
consumes less time than the conventional
flexble fiberoptic bronchoscopy.

Pediatric fibroptic intubation:

Fiberoptic intubation in pediatric patients with difficult airway could be a challenging task and the
presence of craniofacial dysmorphisms presents additional challenges to tracheal intubation. It is more
difficult to perform this procedure in pediatric patients than in adults mainly because of smaller airways in
pediatric patients which make the manipulation of the fiberoptic more difficult since any small movement
of the tip of the firberoptic scope runs the risk of touching the mucosa of the nasopharynx/trachea. This
will prevent good visualization of the airways and lead to perform back and forth maneuvers of the
fiberoptic scope to get better image. While trying to work around this problem, children have higher rates
of oxygen consumption, significantly shortening the period of apnea that can be safely tolerated. The
anesthesiologist will have to interrupt the procedure to start ventilation and avoid severe desaturation of
the patient. Awake pediatric fibreoptic intubation is a difficult task due to non- cooperation.

Some useful links:

There are some useful links of different airway society, which can be used for reference:

Difficult Airway society (DAS) www.das.uk.com

Oxford School of Anaesthesia www.oxfordanaesthesia.org.uk

Nuffield Department of Anaesthetics www.nda.ox.ac.uk

Society for Airway Management (SAM) www.samhq.com

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