EUROANESTHESIA 2008

Copenhagen, Denmark, 31 May - 3 June 2008

FIBREOPTIC INTUBATION: MODERN CLINICAL PRACTICE 19RC2

ADRIAN C. PEARCE
Department of Anaesthesia
Guy’s and St Thomas’ Hospital
London, United Kingdom

Saturday, May 31, 2008 14:00-14:45 Room C1-M5

Since the first description of flexible fibreoptic intubation (FOI) by Murphy in 1967, there has been a vari-
able uptake of the technique in European countries. Its availability is limited by cost, and practice is required to
master the technique. It is simply not possible for all anaesthetists to go on a course to learn FOI initially and
many anaesthetists find they do not use the technique often enough to remain proficient. In expert hands it
remains the ‘gold-standard’ for intubation through the nose or mouth in the awake or anaesthetised patient,
offering a visual technique with a high success rate and extremely infrequent serious complications. The core
roles of the flexible fibrescope in anaesthetic practice are:
• placement and checking of a double lumen tube or bronchial blocker
• checking the position of a single lumen tube or tracheostomy
• inspection and suctioning of the tracheobronchial tree
• inspection during siting of a percutaneous tracheostomy
• fibreoptic intubation
There have been two notable recent advances in airway management that permit the use of the term ‘mod-
ern’ clinical practice to fibreoptic intubation: low-skill fibreoptic intubation and incorporation of FOI within
national airway management guidelines.

LOW-SKILL FIBREOPTIC INTUBATION

Low-skill FOI, a term apparently first used in 2001, denotes a technique of FOI which requires minimal
skill, is easily learnt and can be mastered by all anaesthetists making it a core skill. Low-skill techniques bring
FOI to all anaesthetists.

FOI VIA A CLASSIC LARYNGEAL MASK OR SIMILAR SUPRAGLOTTIC AIRWAY

There are four described techniques which allow FOI via the laryngeal mask airway and one or more of
these techniques are suitable for use with the Classic, Proseal and intubating laryngeal mask airways. The supra-
glottic airway is functioning as a ‘dedicated airway’, defined by Charters and O’Sullivan [1] as an ‘upper air-
way device dedicated to the maintenance of airway patency while other major airway interventions are antici-
pated or in progress’.
Classic technique
This involves placement of a laryngeal mask and the introduction through it of a fibrescope with tracheal
tube loaded on it, first described in 1991 [2]. The fibrescope is advanced to the lower trachea and the tube
advanced into the trachea. The fibrescope can be used to confirm accurate placement of the tube in relationship
to the carina. This technique has a success rate with minimal training of >90% and is particularly useful with
the Classic (re-usable) laryngeal mask airway. Tips to aid success with the Classic laryngeal mask airway are
described in Table 1.

TABLE 1. FIBREOPTIC INTUBATION THROUGH A CLASSIC LARYNGEAL MASK AIRWAY

Place the laryngeal mask in a good position

A size 6.0 mm tracheal tube will usually go through the size 3/4 laryngeal mask airway and size 7.0 mm
through a size 5
Check that the selected tracheal tube can be advanced through the stem before use
A long tube is required, so consider a microlaryngeal, armoured or long north-facing RAE tube
It is a tight fit between tube and stem so make certain the tube cuff is flat and lubrication is used
The laryngeal mask airway can be left in-situ unless access to the mouth is required
A tube exchange catheter can be placed down the originally inserted tube which will allow removal of
the tube and laryngeal mask airway and re-insertion of any size/design tube over the catheter

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Aintree catheter
The Aintree catheter [3] is a hollow bougie designed to fit over the intubating fibrescope. It is a semi-rigid tube
with a length of 56 cm and internal diameter 47 mm. FOI through the Aintree catheter is described in Table 2.

TABLE 2. FIBREOPTIC INTUBATION USING AN AINTREE CATHETER

Place a Classic laryngeal mask or other similar supraglottic airway

Confirm adequacy of ventilation through the laryngeal mask airway
Slide the Aintree catheter onto fibrescope
Advance fibrescope through the lumen of the laryngeal mask airway (Figure 1a)
Position fibrescope in the distal trachea
Hold fibrescope still and advance the Aintree catheter (Figure 1b)
Remove fibrescope, stabilise the Aintree catheter and remove the laryngeal mask airway (Figure 1c)
Intubate with a tracheal tube 7.0 mm or greater over the Aintree catheter (Figure 1d)
Confirm correct position of the tracheal tube by capnography or fibrescope

FIGURE 1A FIGURE 1B

Fibrescope with Aintree catheter passed through lumen With the fibrescope tip in lower trachea,
of laryngeal mask Aintree catheter will be advanced and fibrescope removed

FIGURE 1C FIGURE 1D

Stabilising the Aintree catheter in place and removing Railroading a 7.0 mm tube over the Aintree catheter
the laryngeal mask

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A recent study [4] in manikins showed that the Aintree catheter worked well with both the Classic and
Proseal laryngeal mask airways, with a 95% success rate in about 60-90 s. There are a number of case reports
of successful use, a short review [5] of its use in airway ‘rescue’ in 14 cases and several small published series
with successful use even by inexperienced anaesthetists [6]. The author has used it successfully on three occa-
sions in difficult cases. A recent case report [7] detailed its successful use in a 445 kg patient in whom awake
FOI had failed. A size 5 Proseal laryngeal mask airway was placed under topical anaesthesia and anaesthesia
induced with sevoflurane. Intubation was successful through the proseal in the anaesthetised patient. The
Aintree catheter is available from Cook Medical (www.cookmedical.com) and a poster detailing its use is avail-
able on the internet [8].
Arndt Airway Exchange Catheter set
The Arndt system is also available from Cook Medical. At the time of writing the author has used the sys-
tem successfully but as yet there are no published articles in peer-reviewed journals. The steps are described in
Table 3.

TABLE 3. FIBREOPTIC INTUBATION USING AN ARNDT AIRWAY EXCHANGE CATHETER

Place a laryngeal mask or other similar supraglottic airway

Advance the fibrescope (without tube) to the distal trachea
Insert the wire anterogradely through the working/suction channel of the fibrescope
Check through the fibrescope that the wire has entered the tracheobronchial tree
Remove the fibrescope leaving the wire in the airway
Insert the catheter over the wire
Remove the laryngeal mask airway leaving the catheter in place
Intubate over the catheter with the selected tube (minimum ID 5.0 mm)
Remove catheter and confirm correct position of tracheal tube

Fibreoptically placed bougie/introducer

This technique was described in a letter [9]. It has not become widespread. In the author’s view it is quite
difficult to manipulate a standard introducer and 4.0 mm fibrescope in the stem of a Classic laryngeal mask but
the author has been more successful using a 3.1 mm fibrescope. The steps are described in Table 4.

TABLE 4. FIBREOPTIC INTUBATION USING A FIBREOPTICALLY-PLACED BOUGIE OR INTRODUCER

Place a laryngeal mask airway

Insert fibrescope into stem and view the larynx from above
Insert a bougie/introducer alongside the fibrescope
Pass the introducer through the laryngeal aperture under fibrescopic control
Advance the introducer fully into the airway - it may need to be rotated through
180° to avoid the anterior tracheal wall
Remove fibrescope, laryngeal mask airway, and intubate over the introducer

ORAL INTUBATION THROUGH A BERMAN, WILLIAMS, OVASSAPIAN OR OTHER AIRWAY

Several oral airways have been produced through which it is possible to advance the fibrescope and tube.
The oral airway prevents biting of the fibrescope and is a conduit to the vocal cords. The Berman (www.vital-
signs.com) is available in the UK in sizes 8, 9 and 10 mm but seems to be available in seven sizes in the USA.
If the correct size for the patient is chosen (generally the largest possible so that the tip engages in, or near, the
vallecula), the fibrescope passes easily to the larynx and into the trachea. The tube can be advanced through the
Berman airway and the airway is flanged so it can be removed over the inserted tube. The Williams airway
(Anesthesia Associates, www.ainca.com) is not flanged but can be removed after removal of the tube connec-
tor. It is unfortunate that the largest Berman available is 10 mm because this is not long enough for many large
males. A recent study compared the Berman and Williams airway as conduits for oral FOI in sixty patients [10].
The chance of gaining an unobstructed view of the larynx was greatest with the Williams. Another suitable air-
way is produced by VMB (Bronchoscope airway, www.vbm-medical.de).

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NASAL FOI WITH A LARYNGEAL MASK AIRWAY IN PLACE FOR VENTILATION
Novices who are trying to use a fibrescope for nasotracheal intubation without training will do best when
ventilation is continuous whilst the operator tries to find the larynx. One technique is to place a laryngeal mask
airway and use this to maintain ventilation and anaesthesia whilst inserting the fibrescope through the nose
advancing the scope to a depth of 13-14 cm. Usually the view seen is of the back of the laryngeal mask and if
this is now removed slowly the laryngeal aperture is ‘straight ahead’.

AIRWAY MANAGEMENT STRATEGY

A major development in the last 5 years has been the publication of national guidelines for airway man-
agement by several European countries. A national guideline will take account of the culture, equipment, knowl-
edge and training in that particular country and the place of FOI will vary from being integral to non-existent.
Clearly there is no point in suggesting a role for FOI in a national guideline unless it is a core skill. There is
much ‘blurring’ of the difference between the aspirations of a guideline and actual practice in operating rooms.
Most guidelines have developed along the lines of suggesting an initial airway plan (Plan A) and a back-
up plan (Plan B). These plans are for the unanticipated and anticipated situations and will apply to both anaes-
thetised and ‘awake’ patients. The role of the flexible fibrescope, which is a tool for intubation and not ventila-
tion, can be summarised as described below.

UNANTICIPATED DIFFICULT DIRECT LARYNGOSCOPY IN ELECTIVE SURGERY

In this scenario the patient is anaesthetised (asleep) and long-acting muscle relaxants administered. It is one
of the scenarios covered by the UK Difficult Airway Society guidelines [11] which are freely available in poster
form from its website (www.das.uk.com).
Plan A: Attempt intubation by optimal direct laryngoscopy
Plan B: Maintaining general anaesthesia attempt low-skill FOI, or high-skill FOI for experienced
users, during apnoea or with concurrent ventilation
Plan C: If ventilation is difficult or FOI unsuccessful, proceed to oxygenation by facemask or
laryngeal mask and awaken patient
(Plan D is emergency oxygenation in the ‘can’t-intubate, can’t-ventilate’ scenario)
ANTICIPATED DIFFICULT INTUBATION
The choice of technique may depend on whether facemask ventilation is expected to be easy or difficult,
and is also influenced by the presence of a full stomach. Options (involving FOI) are:
For difficult direct laryngoscopy and:
known or expected easy facemask ventilation
• asleep, low or high-skill FOI with or without concurrent ventilation
• awake FOI
known or expected difficult facemask ventilation
• awake FOI
• asleep FOI after placement of transtracheal catheter for ventilation
known or expected difficult facemask ventilation and full stomach
• awake FOI
MAINTAINING RESPIRATION OR VENTILATION DURING FOI
There is an inherent safety in an intubation technique which allows ventilation at the same time. This
occurs during awake FOI since the patient maintains their own spontaneous respiration during the whole
endoscopy and intubation procedure. Ventilation can also be continued during FOI in the anaesthetised patient
by maintaining spontaneous respiration and abolishing laryngeal reflexes by deep anaesthesia or topical anaes-
thesia. A recent study [12] compared target-controlled infusion of propofol with inhalational anaesthesia with
sevoflurane for FOI in anaesthetised patients maintaining spontaneous respiration. More desaturation occurred
in the propofol group. For the anaesthetised, paralysed patient Rüsch have produced two connectors (Universal
adaptor, www.ruesch.de) designed to fit between a facemask or laryngeal mask and the breathing system. The
connector has a membrane with a 4 mm hole designed to produce a gas-tight seal around a standard intubating
fibrescope. It is also possible, if intubating through a supraglottic airway, to place a standard bronchoscope con-
nector on the tracheal tube once it is within the stem and ventilate through the tracheal tube.

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Another possibility is an adapted facemask from VBM (www.vbm-medical.de) with a suitable hole. Whilst
this can be used with spontaneous or manual ventilation, its use has been examined in a French study [13] using
pressure support ventilation (PSV) during FOI. Thirty-two patients with ENT cancer and at least two criteria for
anticipated difficult intubation underwent FOI whilst anaesthetised with target-controlled infusion of propofol.
The propofol blood level was set initially at 3 µg/ml but adjusted to maintain anaesthesia with spontaneous res-
piration. Glottic anaesthesia was obtained with 3 ml 2% lidocaine through the fibrescope before intubation. The
patients were randomised to spontaneous respiration or pressure support ventilation with 10 cmH2O, and
patients in the PSV group maintained higher tidal volumes and a lower end-tidal carbon dioxide.

AWAKE FOI
SEDATION
Opioids produce good conditions for awake FOI providing analgesia and inhibition of the glottic and gag
reflexes. However, there is the potential for hypoventilation or apnoea and a very careful watch should be main-
tained on the adequacy of respiration. Sedation regimes for awake FOI are a matter of clinician preference or
experience but usually involve an opioid, benzodiazepine or hypnotic either as sole agent or in combination, by
bolus increments or manually adjusted infusion. It is surprisingly easy to induce general anaesthesia inadver-
tently and the author would recommend the simultaneous use of no more than two classes of analgo-sedative
drugs. A recent advance for many practitioners is the incorporation of target-controlled infusions (TCI) of
remifentanil or propofol for sedation/analgesia. TCI could be expected to produce rapid, controllable and stable
levels of sedation. Individual practitioners have their own favourite ‘recipe’. A recent study compared TCI
remifentanil with TCI propofol in 24 patients undergoing awake FOI [14]. Remifentanil produced better condi-
tions for endoscopy and intubation, but with more chance of recall.
The use of awake FOI may be the primary Plan A for intubation and there must be an appropriate Plan B.
Depending on the circumstances the options for Plan B include:
• a more experienced practitioner undertaking awake FOI
• placing a laryngeal mask and using this as a conduit for awake FOI
• an anterograde wire or catheter assisted FOI
• retrograde wire assisted
• surgical tracheostomy
Fibrecapnic intubation was described in 2006 and involves placing a specially constructed capnography
catheter through the working channel of the fibrescope. The catheter may be advanced into the trachea and suc-
cessful tracheal location confirmed by capnography. The fibrescope can be advanced over the catheter into the
trachea. A series of 40 consecutive intubations in 37 patients with advanced head and neck cancer was described
[15]. Topical anaesthesia of the airway was obtained with lidocaine and sedation with 1% propofol run at an
average of 15 ml/hr. Eighty percent of intubations were achieved within 4 min.
The place of awake FOI as a core skill (that is, a competence for all anaesthetists) remains in doubt in many
countries. A recent study of trainees in the UK and Ireland [16] found that trainees considered it necessary to
undertake about 10 awake FOI to achieve competence but the median actual number achieved by the time of
the last training year was only four.

THE FUTURE
Flexible FOI is undoubtedly a highly successful versatile, ‘gold-standard’ procedure which can be used to
manage the majority of difficult airway situations. However, the fibrescope is expensive to purchase and main-
tain, requires decontamination between patients and is easily damaged. In the UK there are now very strict pro-
cedures for decontamination which require sterilisation of the device before and after use. Modern decontami-
nation procedures are no longer conducted within the operating theatre environment and the fibrescope has to be
sent to a central location to ensure quality control. Stimulated by the threat of bovine spongiform encephalopa-
thy (mad-cow disease), the prevailing culture in the UK is to use disposable airway equipment. For routine dif-
ficult intubation (difficult direct laryngoscopy) it is likely that a videolaryngoscope will become popular due in
part to its ease of use, no requirement to attend a course of training, single use plastic inserts and reasonable suc-
cess rate. Other possibilities are rigid stylets, rigid fibrescopes and systems built around fibrebundles.

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KEY LEARNING POINTS

• Low-skill fibreoptic intubation techniques are core skills

• Fibreoptic intubation through a supraglottic airway provides a very effective ‘Plan B’ for unexpected
difficult intubation
• Target-controlled infusions of propofol or remifentanil provide good quality sedation for awake intu-
bation
• A primary airway management plan of awake fibreoptic intubation may fail and must be matched
with a sensible ‘Plan B’
• The supremacy of flexible fibrescopes is being challenged by other devices such as videolaryngoscopes

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