This technique has a very important place in the management of the patient with the difficult airway, although the use of supraglottic airway devices and video laryngoscopy have decreased the frequency of its use. Because this procedure requires equipment that you may not have immediately nearby and takes a little while to set up, it’s probably not the first thing you should reach for in a crash airway. Where this procedure shines is in one of those patients with a slow burn terrifying airway – angioedema that is progressing, epiglottitis, previous oropharyngeal cancer with distorted anatomy.

A few considerations:

This is not a procedure that you should attempt for the first time on an actual difficult airway – familiarize yourself with your equipment prior to attempting an intubation because some of the mechanics of the scope are not intuitive. This may be something to practice on that next easy altered/overdose intubation.
Fiberoptic intubation is generally done sitting up, as an AWAKE procedure – this requires a cooperative patient
Because there is a risk of gagging/vomiting with awake intubation, keep patient NPO (seems obvious) and consider pre-treatment with antiemetics.

Keeping the patient upright can help decrease risk

Consent:

Risks: discomfort from the procedure, epistaxis/oropharyngeal bleeding, trauma to the oropharyngeal/nasal structures, broncho/laryngospasm, toxicity from topical anesthetics, hypoxia, aspiration, cardiac arrythmias, failure of procedure, need for a surgical airway, cardiac arrest, death
Alternatives: video laryngoscopy, direct laryngoscopy, surgical airway, delayed intubation, non-invasive ventilation
Contraindications: patient inability to cooperate, patient refusal, skull base fracture (if using nasal route), allergy to local anesthetic agents

Relative: airway bleeding, unfavorable anatomy, lack of equipment or personnel

Supplies:

Medications –

Lidocaine (or another topical anesthetic) to nebulize/atomize

Ideally higher concentration of lidocaine – 2 or 4%
Viscous lidocaine (usually 2%)

Dissociative meds

Ketamine probably most commonly used,
Low dose midazolam, Precedex (dexmedetomidine) also good options

Sedative +/- paralytic – drawn up and ready to go
Afrin (oxymetazoline)/phenylephrine nasal spray

Nebulizer or atomizer
Non-rebreather mask
Oropharyngeal/nasopharyngeal airway
Suction set up x 2

Have one set up for a Yankauer and one that will be hooked up to the scope

Intubating fiberoptic scope – ideally a disposable one

Make sure that you have a scope that is long enough. Some EDs carry shorter scopes for nasopharyngoscopy – these may not easily reach into the airway when loaded with an ETT

Videoscope set up – Storz/Glidescope screen

If using non-disposable bronchoscope, will likely need full bronchoscope tower

Endotracheal tube

Ideally a longer one intended for nasotracheal intubations – anesthesia will usually have them in the OR

Lubricant for tip of scope
Syringe for inflating the cuff
Twill tie or cloth tape for securing the ETT
Slip tip syringe for lidocaine topicalization of the cords

Airway backups including surgical airway supplies

Scope Basics:

The scope should be held with the LEFT hand with the index finger on the suction button and the thumb on the controller lever

Pulling the lever DOWN with move the tip ANTERIORLY

Pushing the lever UP will move the tip POSTERIORLY

To move the tip left or right, you turn with your wrist which turns the entire scope. You cannot just twist the fiberoptic part of the scope.
Most scopes will have a working channel – for the most part you will not use this until topicalizing the cords.

If you encounter copious, thick secretions that you cannot clear with a Yankauer or the suction on the scope itself, you can use a saline wash with a slip tip to flush some saline through the scope working channel. The saline comes out the scope tip – it can loosen the secretions which you would suction up through the scope

How to Do It

These first steps may seem intuitive but are often missed in the chaos of a difficult airway

Ensure you have 2 points of stable IV/IO access
Stabilize your patient hemodynamically before any attempts at intubation
Assess your patient’s code status

Once you identify that you may be dealing with a difficult intubation, start anesthetizing the airway – this is the key to success in this procedure

If you have a nebulizer – use 5 ml of the 4% solution (gives a dose of 200 mg lidocaine)
For an atomizer with 4% solution – spray 1-2 ml in each naris, and 1-2 ml in the back of the throat
If using less concentrated solution – can use same ml as above (but may need to give additional anesthetic) or use larger volume

Keep dose below toxicity range – do not give more than 3 mg/kg

Have an additional 2-3 ml of 2-4% lidocaine in a 10 ml syringe with 7 ml of air to push through the working channel onto the cords when just about to pass the ETT

While nebulizer is going, gather your supplies and set up your scope
Set up suction cannisters – have one with Yankauer attached and one that will be hooked up to the scope
Plug the scope in to the screen and make sure it works (seems silly, but…)
Load the ETT on the scope

Slide the ETT all the way to the top – there is a small area on the lower part of the controller that has a lip or ridges (depending on the scope). The ETT connector will click onto this to hold the ETT and prevent it from sliding around while you maneuver in the airway

Attach the suction tubing to the scope – you definitely want suction for this procedure

Should attach like this:

A few scopes will need an adapter that looks like this

Once your scope and ETT are prepped, check on your patient.
Apply Afrin or phenylephrine to both nares if you are intending to go through the nose

Coat a nasopharyngeal airway in viscous lidocaine and insert into the naris – this will help further anesthetize as the nasal part of the procedure tends to be the most painful

Look at the nares and try to assess which is larger – you can put a gloved pinky in each naris to feel
Place a non-rebreather on your patient to preoxygenate

When starting intubation, move the mask to over the mouth

Have airway backups within reach
Give your chosen sedative and wait until patient dissociated

Do not paralyze!

Remove nasal airway before insertion of the scope
Lubricate the tip of your scope and insert into the naris perpendicular to the face

Slide the tip of the scope along the bottom of the nasal cavity
Angling upward will cause you to get lost in the sinuses

Continue to slide the tip posteriorly. Once the tip is at the posterior aspect of the nasopharynx, it will turn inferiorly in the posterior pharynx toward the cords. You may need to push the lever up a little to flex the tip posteriorly/downward, but this may not be necessary as the tip will usually slide down on its own without flexing.
Once you have a view of the cords, advance the tip to just above the cords
Topicalize the cords by squirting a few ml of lidocaine through the working channel onto the vocal cords to anesthetize them

Draw up 2-3 ml of 2-4% lidocaine in a 10 ml syringe with 7 ml of air and inject through the working channel onto the cords
The patient will cough – make sure to hold your scope steady. Coughing is desired as it spreads the lidocaine throughout the airway

Advance the scope through the cords

If your patient is awake and spontaneously breathing, you will need to time your advance through the cords to their breaths. Do not run the scope into the cords to avoid laryngospasm
If your patient is awake and cooperative enough, have them stick their tongue out to help keep the cords open

Once through the cords, advance in the trachea until you can see the carina

Once you are parked above the carina – STOP and hold the scope steady.
Have another person railroad/slide the ETT down the length of the scope until you can see the tip of the ETT at the tip of the scope.
If you cannot pass the ETT:

Gently twist while advancing
Insert a direct laryngoscope blade into the oropharynx (Tomahawk or icepick intubation-style) and use to pull the oropharyngeal tissues forward and out of the way of the ETT as it advances

If still unable to advance, cut the disposable laryngoscope at the controller and then use the remaining scope as a bougie while switching out the ETT for a smaller size

DO NOT do this with a non-disposable scope unless you want a whole lot of people very angry with you

Most of the time the ETT will need to be hubbed if nasotracheally intubated
Once ETT in place, give full sedation and/or paralytic ASAP to prevent patient from coughing out ETT
Secure tube in place and remove scope

Oropharyngeal fiberoptic

Generally, much more difficult due to the angle required and the additional soft tissue present during an oral approach

Have second operator using direct laryngoscopy or a jaw thrust maneuver to help pull some of the oropharyngeal tissues out of the way while using fiberoptic scope through the mouth
Other steps will be the same

Resources:

Videos:

https://www.youtube.com/watch?v=YBZFIcIDhQw - longer video by difficult airway group
https://www.youtube.com/watch?v=eyarma4_KQA – sound is quiet, but shows set up and is EM based
https://www.youtube.com/watch?v=wDLrRHS7Urw – NEJM video, shows both nasal and oral approach
https://www.youtube.com/watch?v=9b8RtspI0c8 – helpful walk-through supplies, indications, and methods to topicalize