INTRODUCTION — The flexible bronchoscope is a device that can be used for indirect laryngoscopy for endotracheal intubation, and it is particularly useful when direct laryngoscopy is difficult or impossible or would be dangerous to perform. For endotracheal intubation prior to induction of general anesthesia, flexible bronchoscopy is better tolerated than direct or video-assisted laryngoscopy.
This topic will discuss the equipment and techniques used for flexible bronchoscopic intubation, including patient preparation and sedation for awake flexible bronchoscopic intubation. Retrograde intubation using a percutaneous wire will also be discussed.
While the term "flexible fiberoptic intubation" has been used for this technique in anesthesia, newer bronchoscopes no longer use fiberoptic technology. Therefore, this topic will use the terms "flexible scope intubation" (FSI) for the technique and "flexible intubating scope" (FIS) for the device.
Other airway devices, techniques for endotracheal intubation, and management of the difficult airway for anesthesia are discussed separately. (See "Management of the difficult airway for general anesthesia in adults" and "Airway management for induction of general anesthesia" and "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults" and "Direct laryngoscopy and endotracheal intubation in adults".)
Flexible bronchoscopy for one-lung ventilation and for diagnostic purposes is also discussed separately. (See "Flexible bronchoscopy in adults: Overview" and "Flexible bronchoscopy in adults: Indications and contraindications" and "One lung ventilation: General principles" and "Lung isolation techniques".)
OVERVIEW — FSI may be performed before or after the induction of general anesthesia. Indications for awake intubation include anticipated difficult airway management and the need for a postintubation neurologic exam (eg, unstable cervical spine) (algorithm 1). (See "Management of the difficult airway for general anesthesia in adults", section on 'Awake intubation'.)
FSI is more difficult to perform under general anesthesia than in the awake patient, as the loss of pharyngeal muscle tone leads to upper airway collapse and limited fiberoptic visualization [1].
Most cases are performed using the oral route. The nasal route may be preferred for the patient with a severely limited mouth opening or a strong gag reflex, or if a nasotracheal intubation is necessary for the surgical procedure. Nasal intubation may be better tolerated than oral intubation by the awake patient. In addition, a laryngeal view is often easier to obtain using the nasal approach because the flexible intubating scope (FIS) tends to remain in the midline, with the tip directed at the glottis as it enters the oropharynx.
The risks of nasal intubation include epistaxis, trauma to the nasal turbinates, and submucosal tunneling in the nasopharynx. Preparation of the nasopharynx is necessary prior to the procedure in order to minimize the chance of bleeding. (See 'Nasal preparation' below.)
●Indications and advantages – FSI can be used for patients and clinical settings with impediments to direct laryngoscopy, including the following:
•Limited mouth opening, as the FIS will pass through a narrow oral opening or through the nose
•Abnormal airway anatomy or a mass obstructing direct visualization of the vocal cords
•Unstable cervical spine, such that movement of the spine should be minimized during airway management
•Airway trauma requiring visualization of the larynx and trachea prior to intubation
•Prone or lateral position requiring rescue intubation
●Contraindications and disadvantages – There are no absolute contraindications to FSI. Clinical situations in which FSI may be difficult or impossible include the following:
•Blood or copious secretions in the airway
•Need to observe passage of the endotracheal tube (ETT) through the vocal cords (eg, vocal cord trauma), since the ETT is passed blindly over the FIS (can be mitigated by using a combination technique with video-assisted laryngoscopy)
•Need for rapid control of the airway
•Clinician inexperienced with FSI
•Patient unable to cooperate (for awake FSI)
EQUIPMENT — An assortment of equipment is required for FSI, including the flexible intubating scope (FIS), bite blocks or specialized oral airways, adaptors for ventilation, endoscopy facemasks, antifogging and lubricating agents, equipment for topicalization, and a video monitor. In addition, supraglottic devices designed to facilitate endotracheal intubation can be used along with flexible scopes and may be included with routinely stocked equipment. Equipment for FSI is often kept on a cart that is transported to the intubating location.
Flexible intubating scope — The FIS is used to locate the vocal cords and acts as a stylet for the endotracheal tube (ETT) once the FIS is placed into the trachea.
The FIS consists of a flexible insertion cord that contains either optical fibers or a small camera and a light source at the tip, used to transmit images to an eyepiece or camera head (figure 1 and figure 2). The cord includes a working channel for suction or administration of oxygen or local anesthetic and a cable that allows the operator to flex the tip of the scope. The cord attaches to a handle with a control lever for flexion/extension of the tip, a working channel port, and either an intrinsic video monitor or a connection to an external monitor.
The FIS is available in various sizes. Bronchoscopes used for intubation need to be narrow enough to fit through an appropriately-sized ETT and long enough for the tip to pass beyond the larynx (including the length of the ETT threaded over the shaft):
●Adults – Adult intubating bronchoscopes are typically 60 cm in length, with a diameter of 3.8 to 4.2 mm. Adult scopes fit through a 5.5-mm internal diameter (ID) ETT if adequately lubricated, and they have a working channel 1.2 to 2 mm in diameter.
●Children – Pediatric scopes have diameters of 2.2 mm (accommodated by a 3-mm ID ETT, with no working channel) to 3.1 mm (accommodated by a 4-mm ID ETT, with a working channel 1.2 mm in diameter).
Most FISs are reusable, but disposable single-use flexible videoscopes are available [2,3].The cost-effectiveness of single-use FISs compared to reusable versions depends on local factors, such as number of uses as well as actual capital and maintenance costs [4]; an accounting of the cost of treatment of infections favors the use of single-use devices [5].
Oral airway — Specialized oral airways for FSI are designed to keep the scope in the midline and to act as a bite block for awake oral FSI. Flexible scopes are delicate instruments; a bite block is used to prevent damage to the scope if the patient bites down on it.
There are several types of oral airways for FSI (eg, Ovassapian, Berman, and Williams) (picture 1). The shape is similar to that of a standard oropharyngeal airway used to maintain an open airway for spontaneous or mask ventilation in deeply sedated or anesthetized patients. Because it rests on the base of the tongue and the posterior pharynx, placement of an oral airway may elicit a gag reflex in conscious patients. Therefore, they are used only in patients with general anesthesia, heavy sedation, or with excellent local anesthetic topicalization of the tongue and pharynx.
Oxygenation equipment — Healthy patients are unlikely to require oxygen administration or ventilation during the brief period required for fiberoptic intubation. However, supplemental oxygen should be administered in patients with decreased physiologic reserve or functional residual capacity (ie, pediatric, pregnant, and obese patients), or during difficult FSI, including awake intubation. The use of high-flow nasal oxygen through nasal cannulae or transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is easy to implement during transoral FSI and should be strongly considered. Oxygen delivery with or without ventilation may also be provided with a standard facemask with a bronchoscopic adapter attached, or with a specialized endoscopy mask constructed with a port for the bronchoscope (picture 2).
Other equipment — We usually have the following additional equipment on hand at the time of flexible bronchoscopy:
●Endotracheal tube – Difficulty advancing the ETT through the vocal cords over the FIS is a relatively common problem during FSI. The ETT can be placed in warm saline prior to the procedure. A warmed, softened ETT will usually pass through the vocal cords more easily than an unprepared tube. A flexible ETT, the tapered-tip ETT for use with the intubating laryngeal mask airway (LMA), or a specialized ETT with a bull-nose tip (Parker Flex-Tip) may facilitate advancement. We usually use a Parker ETT for FSI. (See 'Difficulty advancing the endotracheal tube' below.)
●Antifogging agent – An antifogging agent is applied to the tip of the FIS, or the tip is brought to body temperature in warm saline in order to minimize condensation. This maintains a clear image on the lens.
●Lubricating agent – A lubricant facilitates passage of the ETT over the FIS. We use water-based lubricants applied shortly before laryngoscopy, keeping in mind that they can become sticky as they dry. Petroleum-based lubricants have traditionally been avoided in the past in order to minimize damage to the outer coating of the FIS shaft, but this is not a problem with newer scopes. There is a theoretical concern for the development of exogenous lipoid pneumonia with petroleum- or silicone-based lubricants due to deposition of lipids in the lung, however the small amounts needed for FSI are likely insufficient to be clinically significant. Lubricant should be kept away from the tip of the FIS because it may obscure the view [1].
●Nasopharyngeal airway – A nasopharyngeal airway may be used as a method of applying lubricating agents or topical anesthetics in order to prepare the naris for nasal intubation and can help to assess nasal patency. It can also be used to facilitate ventilation during oral intubation in sedated or anesthetized patients.
●Video monitor – Most modern FISs incorporate a video monitor. This provides a clearer view and allows assisting personnel to see the procedure. An external video monitor should be considered when using an older FIS with an eyepiece.
●Airway preparation equipment – Equipment to anesthetize the airway and/or vasoconstrict the nasal mucosa includes atomizing devices, nebulizers, syringes and needles, cotton pledgets, and cotton swabs.
AIRWAY ANATOMY — The airway begins at the nares, the external openings of the nasal passages. The nasal cavity leads to the nasopharynx, followed by the oropharynx, which extends inferiorly to the level of the epiglottis. The hypopharynx begins at the level of the epiglottis and terminates at the level of the cricoid cartilage, where it is continuous with the esophagus (figure 3) [6].
The larynx is a complex structure of cartilage, muscles, and ligaments, which serves as the inlet to the trachea. When viewed from the pharynx, as during fiberoptic bronchoscopy, the larynx begins at the epiglottis (picture 3). The most superior structures within the laryngeal cavity are the false vocal cords. Beneath these are the true vocal cords. The space between the vocal cords is termed the glottis [6].
The trachea begins at the level of the cricoid cartilage and extends to the carina; this length is 10 to 15 cm in the adult (picture 4). At the carina, the trachea bifurcates into the right and left mainstem bronchi (picture 5) [6].
Flexible scope images of the upper airway have posterior structures at the lower part of the image when the operator is standing at the patient's head. When the operator is facing the patient, posterior structures appear at the upper part of the image, rotated 180 degrees.
PATIENT PREPARATION — Preparation of the patient for FSI may include administration of antisialagogues; aspiration prophylaxis; topical vasoconstrictors for nasal intubation; and, if awake intubation is planned, local anesthetic topicalization and sedation.
Antisialagogues — Airway-drying agents (antisialagogues) should be administered prior to FSI whether it is performed awake or after induction of general anesthesia. Even tiny amounts of secretions or blood on the optical element can make fiberoptic bronchoscopy difficult or impossible. Secretions can also decrease the efficacy of topical anesthetics. Antisialagogues should be administered at least 15 minutes prior to intubation to achieve optimal effect. We administer glycopyrrolate 0.2 mg intravenously (IV) at least 15 minutes before beginning the procedure.
Aspiration prophylaxis — In the patient at high risk for aspiration (table 1), medication should be administered preoperatively to increase gastric pH and possibly to decrease gastric volume. The choice of these medications is discussed more fully separately. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Premedication'.)
Our approach to patients at high risk of aspiration who will undergo FSI is as follows:
●For patients at high risk of aspiration because of recent food ingestion, we administer an H2 receptor antagonist (eg, famotidine 20 mg IV, ideally 40 to 60 minutes prior to induction) and metoclopramide (10 mg IV over one to two minutes).
●For fasted patients who are at high risk of aspiration of acidic gastric secretions (eg, severe gastroesophageal reflux disease [GERD], pregnancy), we administer an H2 receptor antagonist, metoclopramide, and also usually administer sodium citrate 30 mL by mouth (PO).
●We position patients at high risk of aspiration head-up for induction and intubation.
Issues to consider when planning FSI for patients at risk for aspiration include:
●Additional time to intubation and airway protection with FSI versus direct laryngoscopy or videolaryngoscopic intubation.
●Cricoid pressure may make FSI more difficult.
●Topicalization can impair airway reflexes.
Airway topicalization can compromise airway protective reflexes and should be performed selectively but thoroughly in patients at high risk of aspiration. In such patients, the oropharynx can be anesthetized and topical glossopharyngeal nerve blocks can be performed in order to blunt the gag reflex, but laryngeal and subglottic anesthesia should be avoided until immediately prior to intubation. This can be accomplished by spraying local anesthetic solution through the flexible bronchoscope as it is advanced during the process of laryngoscopy and intubation. (See 'Airway anesthesia' below.)
The key to awake intubation in the patient with a full stomach is a smooth course, with avoidance of gagging, coughing, and vomiting. Whenever possible, the intubation should not be rushed. Rather, adequate time should be allowed for full local anesthetic effect.
Positioning — Usually, FSI takes place in the sitting/beach-chair, lateral decubitus, or supine positions, but it has also been described in the prone position as a rescue technique [7-9].
Awake patients should be placed in the lateral or sitting position, which can improve visualization of the glottis compared with the supine position [10]. When performing FSI with the patient in the sitting or beach-chair position, the clinician should stand at the patient's side [1].
Supine positioning is typically used in patients under general anesthesia, with the clinician at the patient's head (picture 6). With the patient supine, the laryngeal view through the flexible intubating scope (FIS) is in the same orientation as during direct laryngoscopy, and the patient and clinician are already in the optimal position to perform mask ventilation or other airway maneuvers, if necessary (picture 6).
Nasal preparation — For nasal intubation, a topical vasoconstrictor should be applied to the nasal mucosa in order to reduce the chance of bleeding with passage of the FIS and endotracheal tube (ETT). Commercially available nasal decongestants containing either oxymetazoline 0.05% or phenylephrine 0.5% may be used to constrict the vessels of the nasal mucosa. We administer two sprays of phenylephrine or oxymetazoline to each nostril for vasoconstriction.
Awake intubation — When awake intubation is planned, in addition to the preparations already described, the airway must be anesthetized, and the patient may require sedation. Clinical decision-making regarding the need for awake FSI is discussed separately (see "Management of the difficult airway for general anesthesia in adults", section on 'Awake intubation'). The Difficult Airway Society of the United Kingdom published the first set of guidelines by a national or international society in 2020 [11]. Our approach detailed below is generally similar.
Sedation — The decision to use sedation during awake intubation is made on a case-by-case basis. The goals of sedation for FSI are to have the patient tolerate the procedure and remain cooperative by providing anxiolysis, amnesia, and analgesia [1]. Sedation should not be utilized to compensate for inadequate topicalization [11]. Physiologic monitors should always be applied prior to initiating sedation and it is preferred that a practitioner independent of the person performing the intubation administer any sedation.
Sedative agents should be carefully titrated to maintain adequate respiration, airway reflexes, and cooperative behavior [6]. In general, we prefer medications that can be reversed (eg, opioids) or those with a short duration of action (eg, midazolam, propofol). Minimal sedation should be used for patients in whom there is particular concern for aspiration or respiratory decompensation. Benzodiazepines, opioids, IV hypnotics, and alpha2 agonists can be used alone or in combination. Medications and doses commonly used for sedation during fiberoptic intubation are shown in a table (table 2).
While there are a number of acceptable sedation regimens, and clinical practice varies, we commonly administer one of the following:
●Remifentanil infusion (titrated infusion starting at 0.05 to 0.1 mcg/kg/minute) with or without midazolam (1 to 2 mg IV, repeated as necessary to a total dose of 0.025 to 0.1 mg/kg IV) or
●Dexmedetomidine (bolus 1 mcg/kg IV over 10 minutes, followed by infusion of 0.2 to 1 mcg/kg/hour), with or without midazolam as above, or
●Incremental doses of midazolam as above, with fentanyl (25 to 200 mcg IV in divided doses).
Patient-specific or situational factors will influence the choice of a sedative regimen. Remifentanil has the benefit of rapid onset, easy titratability, and profound blunting of airway reflexes; its primary disadvantage is respiratory depression. Dexmedetomidine provides greater anxiolysis and sedation than a remifentanil-only regimen but has a prolonged time to onset of action and is not as rapidly titratable.
Airway anesthesia — For awake intubation, the airway must be anesthetized using topical anesthetics or nerve blocks. Some nerve blocks are performed by injection (eg, superior laryngeal blocks), others by topical, mucosal application at sites near the nerves (eg, topical glossopharyngeal block, sphenopalatine and anterior ethmoidal blocks) (see 'Superior laryngeal nerve block' below and 'Glossopharyngeal nerve block' below and 'Nerve blocks for nasal cavity' below). Prior to beginning the intubation procedure, adequacy of topicalization should be confirmed with an oral airway or a Yankauer suction catheter [11].
Topical anesthesia — Topical anesthesia should be used on the base of the tongue, the oropharynx, the hypopharynx, and the laryngeal structures. This can be achieved by direct application of local anesthetic ointment or gel, by the use of an atomizer or nebulizer, or by the "spray-as-you-go" method, which involves intermittently injecting local anesthetics through the suction port or working channel of the FIS as it is advanced towards the trachea [6]. Lidocaine is the most commonly used topical local anesthetic because of its rapid onset, high therapeutic index, and availability in a wide variety of preparations and concentrations. We limit the total dose of lidocaine to 5 to 7 mg/kg in order to avoid systemic toxicity; some sources set 9 mg/kg as the maximum dose [11]. (See "Subcutaneous infiltration of local anesthetics", section on 'Systemic toxicity'.)
We use an atomizer to apply 4% lidocaine to the oropharynx and tongue, with supplemental application to the larynx via the working channel of the FIS. Alternatively, various nerve blocks may be utilized, particularly the glossopharyngeal nerve block, superior laryngeal nerve block, and transtracheal block.
Nasal anesthesia — When nasal intubation is planned, in addition to the airway anesthesia described above, the nasal passages must be anesthetized. We use a nasopharyngeal airway liberally coated with lidocaine ointment mixed with 1% phenylephrine in order to provide vasoconstriction, anesthesia, and lubrication for passage of the ETT.
Alternatively, direct application of a combined local anesthetic and vasoconstrictor solution using cotton swabs or cotton pledgets is also effective for both anesthesia and vasoconstriction of the nasal mucosa; options include [6]:
●Cocaine 4%
●Lidocaine 2 to 4% with epinephrine
●A 3:1 mixture of 4% lidocaine and 1% phenylephrine
●A 1:1 mixture of 4% lidocaine and 0.05% oxymetazoline
Transtracheal injection — The transtracheal block is a form of topical anesthesia of the trachea achieved by percutaneously injecting local anesthetic into the tracheal lumen. As a result of the coughing elicited by the block, the injected local anesthetic is nebulized and provides additional anesthesia of the inferior larynx and vocal cords. We often perform this block when we have access to the neck.
●Equipment – Tuberculin syringe or a 25-gauge needle with lidocaine 1 to 2%; 20-gauge angiocatheter attached to a 5-mL syringe containing 3 mL saline; syringe containing 3 to 5 mL of lidocaine 2 to 4%.
●Positioning – Position the patient supine with the neck in slight extension, if possible. Stand at the side of the patient with the dominant hand closest to the patient.
●Technique – Identify the midline of the cricothyroid membrane as the needle insertion site and raise a small skin wheal with local anesthetic using a tuberculin syringe or a 25-gauge needle. Advance the 20-gauge angiocatheter with the attached saline-filled syringe through the skin perpendicularly while aspirating. When air is freely aspirated, advance the sheath of the angiocatheter, remove the needle, and attach a syringe containing 3 to 5 mL of 2 to 4% lidocaine to the catheter sheath that has been left in place. Confirm the sheath position by aspiration of air, warn the patient to expect vigorous coughing, and rapidly inject the local anesthetic during inspiration. The sheath of the angiocatheter may be left in place until the intubation is complete in case more local anesthetic is needed and to decrease the likelihood of subcutaneous emphysema.
Nerve blocks — In addition to topical anesthesia, nerve blocks can be performed in order to anesthetize the nasopharynx, oropharynx, glottis, and trachea prior to awake intubation.
Glossopharyngeal nerve block — We usually perform a glossopharyngeal nerve block using the topical method when performing awake intubation with a video laryngoscope, or for patients with a pronounced gag reflex. This block primarily targets the lingual branch of the glossopharyngeal nerve (cranial nerve [CN] IX), providing anesthesia to the posterior third of the tongue and blocking the afferent limb of the gag reflex. Some blockade of the more proximal branches of CN IX may be achieved, providing anesthesia of the valleculae, the anterior surface of the epiglottis, the posterior and lateral walls of the pharynx, and the tonsillar pillars.
●Injection method
•Equipment – Tongue blade or Macintosh 3 laryngoscope; 25-gauge spinal needle attached to a 5-mL syringe containing 1 to 2% lidocaine.
•Positioning – Place the patient in the sitting position and stand facing the patient on the contralateral side of the nerve to be blocked. Instruct the patient to open his/her mouth widely and to protrude the tongue.
•Technique – With the nondominant hand, displace the tongue medially with a tongue blade or a Macintosh 3 laryngoscope blade, forming a gutter or trough along the floor of the mouth between the tongue and the teeth. The gutter ends in a cul-de-sac formed by the base of the palatoglossal arch (also known as the anterior tonsillar pillar), which is a U- or J-shaped structure starting at the soft palate and running along the lateral aspect of the pharynx. Insert a 25-gauge spinal needle 0.25 to 0.5 cm deep at the base of the palatoglossal arch, just lateral to the base of the tongue, and perform an aspiration test. If air is aspirated, the needle has been advanced too deeply (the tip has advanced all the way through the palatoglossal arch) and should be withdrawn until no air can be aspirated; if blood is aspirated, the needle should be redirected more medially. Inject 2 mL of 1 to 2% lidocaine, and repeat the procedure on the contralateral side.
●Topical method – This block can also be performed topically by holding a 4% lidocaine-soaked pledget or cotton-tipped applicator at the injection site for three to five minutes on each side.
Superior laryngeal nerve block — This block provides anesthesia of the hypopharynx and upper glottis, including the valleculae and the laryngeal surface of the epiglottis. Several different landmarks may be used: the greater cornu of the hyoid bone, the superior cornu of the thyroid cartilage, and the thyroid notch. We rarely perform these blocks, as adequate anesthesia can usually be achieved with less invasive techniques.
●Equipment – 25-gauge spinal needle attached to a 5-mL syringe containing 1 to 2% lidocaine.
●Techniques – Options include the following:
•Greater cornu of the hyoid bone – Identify the greater cornu of the hyoid and walk a 25-gauge needle off the cornu of the hyoid bone in an anterior-inferior direction. A slight resistance is felt as the needle is advanced through the thyrohyoid membrane, usually at a depth of 1 to 2 cm (2 to 3 mm deep to the hyoid bone). Perform an aspiration test. If air is aspirated, the needle has passed too deep and entered the pharynx; the needle should be withdrawn until no air is aspirated. If blood is aspirated, the needle has cannulated either the superior laryngeal artery or vein or has cannulated the carotid artery; the needle should be directed more anteriorly. When satisfactory needle placement is achieved, inject 2 to 3 mL of 1 to 2% lidocaine as the needle is withdrawn. The block is repeated on the opposite side.
•Superior cornu of the thyroid cartilage – Identify the superior cornu of the thyroid cartilage and walk a 25-gauge needle off in an anterior-superior direction. Perform an aspiration test and inject 2 to 3 mL of 1 to 2% lidocaine. The block is repeated on the opposite side.
•Thyroid notch – In some patients, the easiest landmark to identify may be the thyroid notch. Palpate the thyroid notch, and trace the upper border of the thyroid cartilage laterally for approximately 2 cm. Pierce the thyrohyoid ligament with a 25-gauge needle just above the thyroid cartilage at this location, and advance the needle in a posterior and cephalad direction to a depth of 1 to 2 cm from the skin. Perform an aspiration test and inject 2 to 3 mL of 1 to 2% lidocaine. Repeat the block on the opposite side.
Nerve blocks for nasal cavity — We typically perform the sphenopalatine and anterior nerve blocks for awake nasal FSI.
●Sphenopalatine nerve block – This block provides anesthesia of the nasal cavity, as well as the roof of the mouth, soft palate, and tonsils.
•Equipment – Long, cotton-tipped applicators or cotton pledgets soaked in either 4% cocaine or 4% lidocaine with epinephrine 1:200,000; bayonet forceps (if using pledgets).
•Technique – Apply the cotton-tipped applicator along the upper border of the middle turbinate at an approximately 45-degree angle to the hard palate and directed posteriorly until the upper posterior wall of the nasopharynx (sphenoid bone) is reached. The sphenopalatine ganglion underlies the mucosal surface at this point. The applicator is left in place for approximately three to five minutes.
Alternatively, cotton pledgets soaked in the local anesthetic solution may be used and applied to the nasal cavity in the same manner using bayonet forceps.
●Anterior ethmoidal nerve block – This block provides anesthesia of the anterior portion of the nasal cavity.
•Equipment – Long, cotton-tipped applicators soaked in either 4% cocaine or 4% lidocaine with epinephrine 1:200,000.
•Technique – Insert the cotton-tipped applicator into the naris parallel to the dorsal surface of the nose until it meets the anterior surface of the cribriform plate. The applicator is held in position for three to five minutes.
EQUIPMENT PREPARATION — All equipment should be prepared and working prior to beginning the intubation. Our general approach is to do the following:
●Lubricate the shaft of the flexible intubating scope (FIS). (See 'Other equipment' above.)
●Attach oxygen or suction to the suction port, if desired.
●Apply antifogging agent to the tip of the FIS, or pre-warm the tip in saline.
●Prepare the FIS – Check the light, focus the optics, and confirm the proper view orientation and the direction of tip movement with control-lever movement. The control lever bends the tip up and down, allowing it to follow the curves of the airway; rotation of the entire instrument allows the tip to move left and right.
●Obtain a standing stool in order to allow the operator to hold the bronchoscope straight above the patient's head during insertion, if necessary, because control of the movement of the FIS shaft and tip are more effective when the shaft is straight (picture 6).
TECHNIQUE
Oral intubation — Most often, FSI is performed using the oral route. The endotracheal tube (ETT) may be loaded on the flexible intubating scope (FIS) prior to inserting it and moved up the full length of the shaft to the handle in order to avoid interference with movement of the scope. We tape the ETT directly to the scope handle using the pilot balloon to keep it from sliding. If the ETT connector is removed prior to placement on the FIS, it must not be lost; we tape it to the breathing circuit.
A bite block or intubating oral airway may be placed, if desired. When using an intubating oral airway, it is usually easier to place the ETT into the oral airway to a depth of 5 cm, rather than loading it directly onto the FIS. (See 'Oral airway' above.)
The oropharynx should be suctioned prior to inserting the FIS.
The FIS should be oriented so that the tip can be moved up and down in the midline. The FIS is inserted (without a bend at the tip) along the midline of the oropharynx. The FIS must remain in the midline as it is directed around the base of the tongue in order to achieve a satisfactory view of the larynx. When the posterior oropharynx is encountered, the tip should be flexed and advanced around the base of the tongue until the epiglottis or glottis is seen (picture 3). Suction or insufflation of oxygen may be used to clear additional secretions that obscure the view.
Local anesthetic may be sprayed on the cords to decrease reactivity (eg, lidocaine 4%, 1 mL). The FIS should be advanced through the vocal cords to the level of the carina (picture 5), and the ETT advanced over it. The initial depth for oral intubation should be 22 cm for women and 24 cm for men. After visualization of tracheal rings with the FIS, the FIS may then be withdrawn from the ETT, and the position of the ETT can be confirmed with end-tidal carbon dioxide and breath sounds in the usual manner. (See 'Difficulty advancing the endotracheal tube' below.)
Nasal intubation — For nasal intubation, the ETT should be placed in warm saline for several minutes to soften it and make it more flexible in order to minimize bleeding caused by trauma to the nasal mucosa.
The more patent nostril should be selected for intubation. This can be determined by manually occluding each nostril separately and asking the patient to inhale through the nose. The patient will usually be able to inhale more easily through one naris. Alternatively, one can use the scope to visualize the nasal passages or use soft plastic nasopharyngeal airways to gauge patency of the nasal airway.
The ETT should be lubricated, and lubricant should be applied to the selected naris by passing a nasopharyngeal airway liberally coated with 4% lidocaine ointment.
There are two methods for navigating the nasal passage during flexible scope nasal intubation. Loading the ETT onto the FIS and first performing nasal endoscopy ensures that the more favorable route through the nasal passage is taken (beneath the inferior turbinate). This route is associated with less epistaxis and may decrease the incidence of avulsion of a nasal turbinate. The disadvantage of this technique is that one may navigate the FIS through the nasal passage and into the trachea only to find that the nasal passage is insufficient to accommodate the ETT. Gauging nasal patency with a nasopharyngeal airway with an outer diameter at least 1 mm larger than the ETT to be placed can help to mitigate this issue.
Alternatively, a warmed, softened ETT is inserted into the naris to a depth of approximately 14 to 15 cm prior to inserting the FIS [12]. The bevel of the ETT should face the lateral wall of the nasal passage, and cephalad traction should be applied to the ETT as it is advanced in order to minimize the risk of damage to a nasal turbinate and to maximize the odds of the ETT passing inferiorly to the inferior turbinate. The FIS is then passed through the ETT; most often, the larynx is visible as soon as the scope tip exits the ETT. The authors prefer this technique.
The oropharynx should be suctioned prior to inserting the FIS. Secretions that obscure the view may be cleared using suction or insufflation of oxygen through the working channel. The tip should be directed by using the control lever, rotating the entire FIS, and advancing or withdrawing the scope until the cords are directly ahead of the tip. Local anesthetic (eg, lidocaine 4%, 2 to 3 mL) may be sprayed on the cords to decrease reactivity prior to passing through the larynx. The FIS should be advanced through the cords to the level of the carina, and the ETT advanced over it. The initial depth of insertion of the ETT for nasal intubation should be 26 cm for women and 28 cm for men [13]. After visualization of tracheal rings with the FIS, the FIS may then be withdrawn from the ETT and the position of the ETT can be confirmed with end-tidal carbon dioxide and breath sounds in the usual manner. (See 'Difficulty advancing the endotracheal tube' below.)
Retrograde intubation — Retrograde intubation is used most commonly in the unstable cervical spine, in upper airway malignancy, in mandibular fracture, or when the vocal cords cannot be visualized due to blood, secretions, or anatomic variations; it may be used in combination with a FIS. A wire (or catheter) is inserted percutaneously through the cricothyroid membrane and blindly cephalad along the trachea, larynx, pharynx, and out of the mouth or naris; this wire is then used to guide passage of an ETT from the mouth or nose into the trachea.
This technique may be used with or without a FIS. Commercially available retrograde intubation kits have a 0.037-inch guidewire that may not fit through the working channel of some FISs, so compatibility must be checked prior to using this technique with a FIS.
Once the guidewire is retrieved from either the mouth or naris, retrograde intubation begins by securing the wire with a hemostat outside the cricothyroid insertion site in order to avoid pulling through and to maintain tension. When this is performed without an FIS, an airway exchange catheter (AEC) is then threaded over the taut wire until it passes the larynx. After removing the wire, an ETT is advanced over the AEC to the appropriate distance (usually to 22 cm for women, 24 cm for men), confirmed in the usual fashion, and secured.
When a FIS is used for assistance, an ETT is placed on the FIS prior to retrieving the end of the wire from the mouth or naris and passing it through the working channel of the FIS from distal to proximal. The FIS is then passed over the guidewire and into the glottis until resistance is met at the cricothyroid membrane. The hemostat that held the guidewire taut may now be released and the guidewire removed. The FIS is advanced until the carina is visualized and the ETT is passed into the trachea.
The primary advantages to using an FIS for this technique are [1]:
●The trachea is accessed under direct vision
●The FIS can be freely advanced to the carina (past the puncture site), minimizing the potential for the ETT to become dislodged when the wire is removed (due to the short distance between the vocal cords and puncture site)
●Oxygen may be continuously administered via the FIS throughout the procedure (including while the guidewire is still in place)
The main disadvantage to the addition of FIS guidance to the retrograde technique is the need for additional equipment and preparation time, which may not be available in emergency cases.
TROUBLESHOOTING — FSI is a complex procedure that requires practice and may not be straightforward. A number of strategies can be used to improve success.
Difficulty with the view — When laryngoscopy is difficult, it is critical to keep the tip of the FIS in the midline at all times in order to allow visualization of the larynx. The clinician should always be able to recognize the airway structures; if not, the FIS should be withdrawn until the location can be identified.
Collapse of the upper airway, whether from induction of general anesthesia, administration of neuromuscular blocking agents, or from anatomic pathology, can cause difficult visualization or navigation of the oropharynx. Various maneuvers, some performed by an assistant, can be used to open the upper airway and improve visualization:
●Placement of an oral airway (see 'Oral airway' above)
●Jaw thrust (picture 7)
●Pulling the tongue forward with a piece of gauze or Magill forceps (gently so as not to injure the tongue on the bottom teeth)
●Cervical extension (when not contraindicated), which lifts the epiglottis anteriorly and exposes the larynx
●External laryngeal displacement (adjusting the position of the larynx by placing pressure on the neck at the thyroid cartilage)
●Insertion of a direct or indirect laryngoscope blade, which may open the airspace and lift the epiglottis off the posterior pharyngeal wall
●Addition of positive airway pressure, when using an endoscopic mask
In awake patients, instructing the patient to sniff, swallow, vocalize, or breathe deeply can improve visualization of the glottis [10].
If fogging occurs during FSI, the lens may be cleared by gently touching the tip of the FIS to the airway mucosa.
Difficulty advancing the endotracheal tube — Once the FIS has been advanced to the carina, the endotracheal tube (ETT) may be advanced over the FIS. This is a blind procedure, and it is not uncommon to encounter difficulty in advancing the ETT over the scope into the trachea. Several techniques may alleviate this problem:
●Difficulty in advancing the ETT may result from it catching ("hanging up") on the right arytenoid. Turning the ETT 90 degrees counterclockwise may facilitate its passage [14].
●A warmed, softened ETT will usually pass through the vocal cords more easily and with less trauma than an unprepared tube.
●A flexible ETT, a tapered-tip ETT for use with the intubating laryngeal mask airway, or a specialized ETT with a bull-nose tip (Parker Flex-Tip) may facilitate advancement (picture 8 and picture 9) [15].
●The gap between the FIS and the larger ETT may allow the ETT to shift off-center and catch as it passes through the larynx. An Aintree catheter loaded over the FIS within the ETT will minimize this gap, but this must be done prior to inserting the FIS.
●A combination technique may be indicated; that is, the use of laryngoscopy, either direct or indirect, may facilitate clearance of the tongue, elevation of the epiglottis, and advancement of the ETT.
AIRWAY MANAGEMENT FOR PATIENTS WITH COVID-19 — In patients with novel coronavirus disease 2019 (COVID-19 or nCoV), there may be a high risk of aerosol spread of the virus during laryngoscopy and other airway management procedures. Awake flexible scope intubation is a particularly high-risk procedure because of the risk of cough. Airway management and infection control in patients with COVID-19 are discussed separately. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control".)
Flexible bronchoscopy in patients with COVID-19 is also discussed separately. (See "COVID-19: Management of the intubated adult", section on 'Bronchoscopy'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Airway management in adults" and "Society guideline links: COVID-19 – Index of guideline topics".)
SUMMARY AND RECOMMENDATIONS
●Indications for flexible scope intubation (FSI)
•Flexible scope intubation (FSI) is an indirect technique for endotracheal intubation using a flexible bronchoscope. FSI is particularly useful for patients in whom direct laryngoscopy may be difficult or dangerous (eg, limited mouth opening, abnormal airway anatomy, unstable cervical spine). (See 'Overview' above.)
FSI may be difficult or impossible if blood or secretions are in the airway. (See 'Overview' above.)
●Preparation for FSI
•An assortment of specialized equipment required for FSI is usually kept on a mobile cart for easy transport to the anesthetizing location. (See 'Equipment' above.)
•With effective topical airway anesthesia, FSI is better tolerated by the awake or sedated patient than is intubation with direct or video-assisted laryngoscopy. FSI can also be performed after induction of anesthesia. (See 'Airway anesthesia' above.)
•An antisialagogue (eg, glycopyrrolate, 0.2 mg IV) should be administered at least 15 minutes prior to FSI to aid in drying the airway mucosa. If nasal intubation is planned, a topical nasal mucosal vasoconstrictor should be applied before intubation (eg, oxymetazoline 0.05%, two puffs to each nostril three times at five-minute intervals). (See 'Antisialagogues' above and 'Nasal preparation' above.)
●FSI technique - FSI can be used for nasal or oral endotracheal intubation.
•Oral intubation steps are as follows (see 'Oral intubation' above):
-A bite block or intubating oral airway is placed, and the oropharynx is suctioned.
-The endotracheal tube (ETT) is placed into the intubating airway to a depth of 5 cm or is loaded directly onto and secured to the handle of the lubricated flexible intubating scope (FIS).
-The FIS is oriented so that the tip can be moved up and down in the midline and is inserted without a bend at the tip along the midline of the oropharynx (or into the ETT, if in the oral airway).
-The larynx should be visible in the midline; the FIS is passed through the vocal cords to the carina.
-The ETT is advanced over the FIS to 22 cm for women or 24 cm for men.
-The FIS is withdrawn, and the ETT position is confirmed in the usual manner.
•Nasal intubation steps are as follows (see 'Nasal intubation' above):
-A softened (warmed), lubricated ETT should be inserted into the selected naris to a depth of approximately 15 cm.
-After suctioning the oropharynx, the lubricated FIS is passed through the ETT.
-The larynx is usually visible distal to the ETT; the FIS is passed through the vocal cords to the carina.
-The ETT is advanced over the FIS to 26 cm for women or 28 cm for men.
-The bronchoscope is withdrawn, and the ETT position is confirmed in the usual manner.
●Troubleshooting – Various maneuvers may be used to open the upper airway, improve visualization, locate the larynx, and facilitate passage of the ETT. (See 'Troubleshooting' above and 'Difficulty advancing the endotracheal tube' above.)
●Retrograde intubation – When other methods for intubation are not possible, retrograde intubation can be performed with or without the use of a FIS. A wire is inserted into the trachea through the cricothyroid membrane and passed cephalad, exiting the mouth or nose. The wire can be fed through the working channel of the FIS; the FIS, loaded with an ETT over it, is passed over the wire into the trachea. The ETT is then passed over the FIS into the trachea. (See 'Retrograde intubation' above.)
