Anaesthesia, 1992, Volume 47, pages 729-73 1
Editorial
Learning fibreoptic intubation: fundamental problems
Failed tracheal intubation still results in significant mor-
bidity and mortality [I]. Several pre-operative tests have
been proposed to identify patients at risk [2-51.
However, these have not gained general acceptance
because of the incidence of false-positive results [6]. In a
recent article, Frerk assqsed two simple bedside tests
for the prediction of difficult intubation and, in the cases
studied, the two tests combined had a greater specificity
than either test used alone [7]. If these tests taken
together provide a more reliable method of predicting
difficult intubation, how should such a patient be
managed? A logical answer would be to perform an
awake fibreoptic intubation.
The availability of the fibreoptic bronchoscope repre-
sents a significant landmark in the search for a solution
to difficult intubation. Several excellent articles have
discussed the problem of how to instruct trainees in the
technique [&lo], but for some hospitals, problems may
appear at an even more fundamental level. A standard
intubating bronchoscope, light source, adaptor, suction,
sterilising equipment and purpose-built trolley costs
about f10,OOO. The first hurdle may therefore be the
initial purchase. A diagnostic and therapeutic return on
this order of investment may not be immediately
obvious. Managers, and sometimes colleagues in other
specialties, may have to be convinced in the competition
for limited equipment budgets. The case is probably best
presented in a written submission, giving a succinct
account of the clinical and medicolegal problems of
failed intubation.
Once acquired, the bronchoscope must be handled
and maintained with care. It is a delicate instrument,
consisting of insulated glass fibres bound into a flexible
bundle. In addition there is a light guide cable, a
working channel which is used for suction, local anaes-
thetic injection or oxygen insufflation, and angulation
wires to allow movement of the tip in an
anterior-posterior plane. Actual specifications such as
length, diameter and tip angulation, can vary. Those
designed for intubation tend to be longer (600 mm
compared with 550 mm), of smaller diameter (4 mm
compared with 5-6 mm), and possess lesser degrees of
tip deflection and hence field of view (75’ compared with
90-1 20’), than diagnostic bronchoscopes.
Meticulous handling, cleaning and sterilisation are
essential, otherwise repair costs will be high. It is not an
instrument for the casual, unsupervised user and so a
strict policy on its availability may need to be defined.
The insertion cord will only tolerate gentle bending.
Light fibres are easily damaged and each additional
individual broken one causes an incremental deterio-
ration in the optical image. Forcible bending of the
distal tip may fracture the control wires. Following use,
a scrupulous and invariable routine must be observed.
The bronchoscope must always be tested for leaks
before immersion in sterilising solution as seepage
through breaches in the external casing will cause major
damage to the optical system.
0003-2409/92/090729 +03 $03.00/0 @ 1992 The Association of Anaesthetists of G t Britain and Ireland
Before trainees can be taught to use the fibreoptic
bronchoscope, senior members of staff must themselves
first acquire the appropriate skills. Those who have
learned by apprenticeship as a junior may underestimate
the difficulty in acquiring a new skill, possibly unaided,
as a consultant. Therefore, a priority is to provide
opportunities for other senior staff to learn the tech-
nique. How should the technique be taught? Major
differences appear to exist between the U K and the USA
both in the teaching and practice of fibreoptic intuba-
tion. Local anaesthetic techniques seem to predominate
in North America, whereas general anaesthesia features
most commonly in the UK.
There are disadvantages to teaching fibreoptic bron-
choscopy under general anaesthesia. Two main tech-
niques are used. In one, deep anaesthesia is achieved in
the spontaneously breathing patient and the broncho-
scope is usually, but not always, inserted through the
mouth. Skilled assistance is required to maintain the
airway and pollution of the anaesthetic room often
occurs due to leaks. Reported complications include loss
of airway control, desaturation, laryngeal spasm, bron-
chospasm and arrhythmias [ 1 I]. In the second, the
bronchoscope is inserted under light anaesthesia during
apnoea produced by neuromuscular blockade, a tech-
nique which leaves only a limited time for broncho-
scopic insertion and tracheal intubation.
After general anaesthesia has been induced, the soft
palate, tongue and epiglottis approximate to the pos-
terior pharyngeal wall [12]. Little air space is thus left in
the oropharynx for manoeuvring the tip of the broncho-
scope and the view tends to be obscured by the tissues.
Several airways have been designed to overcome this
problem and facilitate the insertion of the
bronchoscope [13]. However, none of the approaches
under general anaesthesia permit the unhurried, sequen-
tial identification of the nasal, pharyngeal and laryngeal
structures, which is possible in the awake subject and
essential when patients with abnormal anatomy or path-
ology are subsequently encountered. In addition, neither
of the techniques prepare the trainee adequately to
perform an awake fibreoptic intubation in a patient with
a difficult airway.
Dykes and Ovassapian [14] recommend that a trainee
learns initially on awake patients who have normal
anatomy, but acknowledge the problem of finding suit-
able subjects o n whom to gain experience. At their
centre it became routine to perform an awake fibreoptic
technique on all patients who required nasal intubation.
If there are reservations about such an approach, the
skills relevant to awake intubation may be acquired on
patients undergoing diagnostic bronchoscopy. Such
individuals readily accept that the ‘magic eye’ is used
with local anaesthesia, and the judicious use of incre-
mental doses of a diluted solution of midazolam usually
ensures cooperation during the procedure and
frequently amnesia as well.
Large numbers of diagnostic bronchoscopies are
729

730 Editorial
carried out each year, mostly under local anaesthesia
and by physicians in respiratory medicine. In 1974 it
was estimated that 15 000 patients a year in the UK
might require diagnostic bronchoscopy [ 151. However, a
postal survey, which had a 90% response rate, indicated
that at least 40 000 of these procedures had been under-
taken during 1983 [16]. Increased cooperation between
physicians and anaesthetists is advantageous to both
doctors and patients alike. The benefit of the presence of
a second doctor when a procedure is being carried out
under sedation is well recognised. In the postal survey,
the commonest major complication (described as life-
threatening or a cause for concern) was respiratory
depression from sedative-narcotic combinations.
Routine administration of oxygen was confined to 18%
cases, despite the fact that arterial desaturation
frequently occurs during endoscopy under sedation. A
consultant anaesthetist, supervising a trainee, could be
responsible for the monitoring, sedation, administration
of local anaesthesia, oxygenation and insertion of the
bronchoscope through the vocal cords. Thereafter the
physician would continue the procedure. The presence
of the anaesthetist would permit the occasional very
uncooperative patient to be given general anaesthesia,
with the opportunity to offer reciprocal teaching of
conventional tracheal intubation to members of the
medical team.
To what extent can the trainee be prepared before his
first fibreoptic bronchoscopy on an awake patient?
Undoubtedly, the most difficult task is to learn to hold,
manipulate and advance the bronchoscope. Since the
angulation produced by the tip lever is in one plane
only, lateral movement of the fibrescope can only be
achieved by rotation, followed by appropriate flexion
and extension. The arrow on the perimeter of the field of
view is an invaluable guide to the orientation of the
instrument. Excellent books and papers on the tech-
nique are available [5, 171 and are worthy of careful
attention beforehand. Familiarity with the anatomy is
essential and study of bronchoscopic photographs, both
normal and abnormal, of the epiglottis, vocal cords and
trachea is helpful. The basic technique of handling of
the instrument can be learned using an airway training
model and bronchial tree. These are relatively inexpen-
sive and many hospitals already possess them for resus-
citation training purposes. Trainees undergoing a
graduated training programme in fibreoptic bronchos-
copy using such models, were shown to have a greater
initial success rate with awake fibreoptic intubation than
those without such preliminary preparation [18]. In
addition, other important aspects such as sedation, local
anaesthetic application, and insertion of the tracheal
tube after bronchoscopy has been achieved, can all be
taught before a real patient is encountered.
There are other advantages to improving one’s
dexterity on patients undergoing diagnostic bronchos-
copy. Diagnostic bronchoscopes are of larger diameter
than those designed for intubation and a better image
and wider field of view is obtained. The usual approach
is via the nasal route, so the angulation required to enter
the larynx is less than that needed using an oral tech-
nique and the tongue does not interfere with insertion.
Several useful tips can assist the beginner. When the
nasal route is used, the position of the head and neck is
important and differs from that required for conven-
tional intubation. Full extension of the neck, either by
removal of the pillow, or the use of a support under the
shoulders, will open up the space around the glottis. The
operator should insert a well-lubricated bronchoscope
13652044, 1992, 9, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.1992.tb03247.x, Wiley Online Library on [12/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
into the more patent nostril and negotiate the nasal
passages under direct vision. Discomfort, trauma and
bleeding are thus minimised. Navigation along the floor
of the nose, below the inferior turbinate, often brings
the epiglottis directly into sight. Loss of view may occur
in the pharynx, as a result of the tip abutting onto
mucosa or being covered with blood or secretions.
Vision is often restored by slight withdrawal of the
fibrescope from the mucosa. Blood or secretions can
usually be removed by suction, although on occasions,
saline may need to be injected through the working
channel, or the instrument completely withdrawn for
cleaning.
It is helpful to remember that, in adults, the distance
between the nares and the epiglottis is about 15 cm. If
structures are difficult to identify in the pharynx, the
operator should be encouraged to pass the scope to
about 12 cm, at which point recognisable structures
often reappear. If the 15 cm mark has been passed and
the glottis is still not visible, the bronchoscope is likely
to be in the oesophagus. When the glottic structures
have been identified, but difficulty is encountered
passing the bronchoscope through the vocal cords, the
patient should be asked to take a deep breath to bring
about maximum abduction of the glottis. One of the
commonest causes of failure of fibreoptic intubation is
movement of the laryngeal structures as a result of
inadequate topical anaesthesia [19]. In such cases
further local anaesthetic should be introduced onto the
vocal cords, via the working channel.
Once the technique has been mastered in patients with
normal anatomy, anaesthetists will be anxious to apply
it to those in whom there are clinical indications.
Fibreoptic intubation is not, however, the answer to
every airway problem. The technique should not be
applied uncritically, particularly if the operator is rela-
tively inexperienced. A discussion on the indications and
possible contraindications for bronchoscopy is therefore
an essential part of training. The most appropriate
candidate for awake fibreoptic intubation is the patient
in whom the potential intubation difficulties are anato-
mical in origin, such that direct vision of the vocal cords
is impossible using the conventional laryngoscope.
Structural or pathological abnormalities involving the
neck, mandible, maxilla, or teeth may contribute to
these difficulties. Those patients in whom there is a risk
of damage to teeth or dental work may also be suitable
candidates, since dental claims form a significant pro-
portion of anaesthetic medicolegal practice.
Some suggested indications for fibreoptic intubation
are more controversial. A case has recently been
advanced for the awake intubation of all emergency
patients who are at high risk from aspiration of gastric
contents [20]. However, aspiration may still occur in the
awake patient, and even the precaution of applying local
anaesthetic only after the vocal cords have been visua-
lised may not always protect a patient from massive
regurgitation and aspiration. The use of the fibreoptic
bronchoscope in patients with severe upper airway
obstruction is also uncertain. Where there is critical
upper airway narrowing as a result of oedema or
tumours, instrumentation may precipitate complete
obstruction even in the awake patient. Tumours may
bleed or pieces might be directly dislodged by the
bronchoscope. In the awake patient, interference with
the upper airway in the presence of epiglottitis has
traditionally been regarded as potentially dangerous.
There are, however, advocates of awake intubation even
in this condition [17]. It should be emphasised that such

techniques are only for the experienced bronchoscopist
and the presence of an ENT surgeon prepared to
perform emergency tracheostomy is mandatory.
The aim of every anaesthetic department should be to
provide a structured training programme in fibreoptic
bronchoscopic intubation. Opportunities to cooperate
with the chest physicians who provide diagnostic bron-
choscopy services should be explored. The acquisition of
confidence and skill in the technique will encourage an
expansion of clinical indications. The threshold for the
use of fibreoptic intubations should be lowered such
that the technique is regularly practised and every
anaesthetist becomes skilled in the art. Bedside tests for
predicting intubation difficulty will only be of value if
positive information elicits a logical response-if in
doubt, intubate awake.
Department of Anaesthesia R.A. MASON
Singleton Hosptial
Swansea SA2 8QA
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Editorial 73 1
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