Fiberoptic intubation in the emergency department (2023)

Cited by (49)

  • Bronchoscopy in the emergency department

    2022, American Journal of Emergency Medicine

    Flexible bronchoscopy has been safely used for decades in ambulatory and critical care settings to aid in the diagnosis and treatment of tracheobronchial tree disorders. Although emergency physicians have the requisite skills to operate and interpret flexible bronchoscopy, no reports exist on the use of bronchoscopy by emergency physicians apart from endotracheal tube placement and confirmation.

    The primary goal of this study was to describe the indications, outcomes and complications of flexible bronchoscopy performed by emergency physicians in an urban academic emergency department.

    This was a single-center retrospective cohort study involving chart and video review of 146 patients over a 10.5-year study period. Patients of any age were included if they had been tracheally intubated or mechanically ventilated and underwent flexible bronchoscopy in the emergency department. After patients were identified, manual chart and video review was used to collect data on patient demographics, indications for intubation, indications for bronchoscopy, details of the bronchoscopy procedure, procedural findings, outcomes of the procedure, complications, provider training levels, and additional bronchoscopies performed after admission. The data was analyzed using descriptive statistics.

    146 patients were included in the study and all bronchoscopies were performed or supervised by attending emergency physicians. After bronchoscopy, 24% of patients displayed improvement in oxygenation or lobar collapse while most patients had no change in clinical status. One patient had temporary hypoxemia after bronchoscopy. When another physician performed a subsequent bronchoscopy during admission, the findings were in agreement with the ED bronchoscopy 86% of the time.

    At our institution, emergency physicians can safely and effectively use flexible bronchoscopy to diagnose and treat critically ill patients.

  • Flexible nasotracheal intubation compared to blind nasotracheal intubation in the setting of simulated angioedema

    2019, American Journal of Emergency Medicine

    Citation Excerpt :

    In these situations, providers may be required to perform nasotracheal intubation by either blind nasotracheal intubation or fiberoptic nasal intubation (FNI) [2,5-8]. Nasotracheal intubation, in the Emergency Department (ED), is typically employed for awake, spontaneously breathing patients that require airway stabilization, as well as patients with suspected cervical spine injuries [6-9] Blind nasotracheal intubation has risks including damage to turbinates, bleeding, and improper placement of the endotracheal tube [7,8]. In addition, providers may be reluctant to preform blind nasotracheal intubation as they are not able to visualize common airway structures key to successful completion of orotracheal intubation.

    Nasotracheal intubation is rarely performed in the emergency department (ED) but may be required in specific situations such as angioedema. Both blind and flexible nasal intubation (FNI) may be utilized; however, the preferred technique is unknown.

    (Video) Awake Fiberoptic Intubation

    We performed a randomized, crossover manikin study using a convenience sample of emergency physicians and medical students from a local community teaching hospital. Using a simulated angioedema model, we sought to compare the time required to successfully perform nasotracheal intubation between traditional blind nasotracheal intubation and FNI. Participants performed nasal intubation with both FNI using the Ambu aScope Slim (Ambu, Ballarup, Denmark) and blind nasal intubation with a Parker Endotrol tube (Parker, CO) in random order. Number of attempts and time to successful intubation (TTI) were compared between treatment devices. Providers were stratified by experience level, defining junior providers as post-graduate level 2 and below (including medical students) and all others as senior providers.

    We enrolled a convenience sample of 20 providers ranging from medical students to attendings. Overall, the TTI did not differ between blind and FNI intubation techniques (difference in seconds; 95% confidence interval) (21.4; −2.1 to 44.9; p = 0.07). This was consistent across provider types: senior providers (26.6; −17.7 to 71; p = 0.24) and junior providers (18.6; −8.3 to 46.5; p = 0.18). Number of attempts was similar between techniques (p = 0.55).

    FNI and blind nasal intubation require similar time to intubation in this simulated model of angioedema.

  • Use of Video-assisted Intubation Devices in the Management of Patients with Trauma

    2013, Anesthesiology Clinics

    Citation Excerpt :

    Therefore, the skill of community emergency physicians with the technique is likely to be similarly variable. Flexible fiberoptic intubation has been used by emergency physicians as a primary device and to rescue failed alternate techniques.48 However, surgical approaches to rescue techniques may be used more frequently than fiberoptic techniques.49

  • Airway Management

    2011, Pediatric Critical Care: Expert Consult Premium Edition

  • Airway Management

    2011, Pediatric Critical Care

  • Airway Management in Trauma: An Update

    2007, Emergency Medicine Clinics of North America

    Citation Excerpt :

    Failure is attributed most often to poor visibility from blood, vomitus, and other secretions. Mlinek and coworkers [53] found that successful ED fiber-optic intubations averaged 2 minutes, whereas failures averaged 8 minutes; they recommended considering alternative approaches if intubation attempts take more than 3 minutes. Fiber-optically guided intubation can be accomplished using the nasal or oral route.

    (Video) Awake Tracheal Intubation in the Emergency Department - John Sakles (SAS2021 Featured Presentation)

    This article reviews the more recent theoretic and practical information that pertains to airway management in the trauma setting. This is followed by a presentation of the newer airway devices that may be advantageous in the management of the airway in trauma as well as a discussion of other devices, techniques, or maneuvers that are useful in the trauma setting but may be underused. Each clinician needs to be knowledgeable about the various airway options and then, based on one's own particular skills and resources, construct an airway management algorithm that works best for him or her. Each clinician needs to be knowledgeable about the various airway options, and then, based on the clinician's particular skills and resources, construct an airway management algorithm that works best.

View all citing articles on Scopus

Recommended articles (6)

  • Research article

    A micromechanical approach to volumetric and surface growth in the framework of shape optimization

    We herewith adopt the physically and micromechanically motivated point of view that growth (resp. resorption) occurs as the expansion (resp. contraction) of initially small tissue elements distributed within a host surrounding matrix, due to the interfacial motion of their boundary. We postulate that the shape of the tissue element evolves in such a way as to minimize a certain functional amongst all possible admissible shapes. The driving force for the motion of the interface describing the surface growth models at the scale of the growing tissue elements is obtained from the identification of the driving force resulting from the shape derivative of the functional to be minimized. The shape derivative expresses as a surface integral involving the surface growth velocity and a conjugated driving force, in line with Hadamard’s structure theorem. Focusing on the total potential energy, the motion of the interface is described within the framework of gradient flows, whereby the interfacial velocity is related to a driving force identified to the jump of the normal component of Eshelby stress at the interface of the growing tissue elements. This formalism is exemplified in the situation of the avascular growth of spheroidal tumors and to bone external remodeling. This brings a dual viewpoint to the macroscopic volumetric growth models which consider production of new mass as a hidden mechanism occurring at a smaller scale, and traduced by a local increase of either density or volume. Volumetric growth at a macroscopic scale appears as the averaging of surface growth mechanisms occurring at the microscopic scale of the growing tissue elements.

  • Research article

    Feasibility and Early Safety of Single-Stage Hybrid Coronary Intervention and Valvular Cardiac Surgery

    The Annals of Thoracic Surgery, Volume 99, Issue 6, 2015, pp. 2032-2037

    Hybrid percutaneous coronary intervention offers an alternative method of revascularization for high-risk surgical populations. We report the outcomes of a single-stage hybrid strategy in valvular cardiac surgery and explore its effects on operative risk and bleeding.

    In a hybrid operating room, 26 patients underwent hybrid surgery consisting of femoral arterial access, then coronary stenting followed by valve surgery, with appropriate heparin dosing. Clopidogrel (300 mg) was given on anesthesia induction in nonreoperative cases, or at the time of cross clamping (after stenting) for reoperative cases.

    (Video) Emergency Nasopharyngoscopy for Angioedema Evaluation

    Mean follow-up was 680 ± 277 days. The planned coronary stenting and surgery was successful in all patients. Major cardiovascular and cerebrovascular adverse events occurred in 1 patient, with no inhospital deaths observed. No vascular complication or stent thrombosis was observed with the described antiplatelet regimen. Outcomes were comparable to those of standard bypass valve replacement surgery.

    This study demonstrates the feasibility and early safety of a single-stage hybrid strategy with coronary stenting followed by valvular surgery in patients at increased surgical risk. Hybrid procedures may lower operative risk by eliminating or reducing the need for bypass grafting.

  • Research article

    Effects of Endovascular Interventions on vWF and Fb Levels in Type 2 Diabetic Patients with Peripheral Artery Disease

    Annals of Vascular Surgery, Volume 33, 2016, pp. 159-166

    von Willebrand Factor (vWF) and fibrinogen (Fb) are associated with hypercoagulability and thrombosis, which are the pathology and symptom of arterial disease. This research aims to study the effects of endovascular interventions on blood vWF and Fb levels in patients with diabetic peripheral artery disease (PAD).

    Totally, 66 type 2 diabetic patients with PAD (intervention group) and 26 type 2 diabetic patients without PAD (control group) were enrolled. These patients are matched at gender, age, and diabetes duration. For PAD patients, percutaneous interventions (balloon dilation or stent implantation) were performed, and blood samples were collected before, during, and after interventions. Then, enzyme-linked immunosorbent assay and prothrombin time-derived method were used to detect the levels of vWF and Fb, respectively.

    For intervention group, vWF and Fb levels in distal ischemic regions (vWF: 231.3%, Fb: 4.97g/L) were significantly higher than that in nonischemic regions (vWF: 147.6%, Fb: 3.91g/L, P value<0.01). After interventions, ischemia was improved, whereas vWF and Fb levels were significantly increased (vWF: 299.2%, Fb: 5.69g/L, P value<0.01). During the 2 weeks after interventions, vWF and Fb levels reached a peak (vWF: 199.3%, Fb: 4.96g/L) and then decreased gradually to lower than the preinterventional levels (vWF: 148.3%, Fb: 3.88g/L, P value<0.05).

    Interventions caused increases of blood vWF and Fb in the first week postintervention, leading to endothelial dysfunction and blood hypercoagulability. It suggested endothelial function protection and anticoagulant therapies should be applied to diabetic PAD patients after interventions.

  • Research article

    Pacemaker Implantation After Transcatheter Aortic Valve Implantation

    The American Journal of Cardiology, Volume 112, Issue 10, 2013, pp. 1632-1634

    Thirty- to 35% of patients after transcatheter aortic valve implantation undergo implantation of a permanent pacemaker (PPM) because of development of atrioventricular block (AVB) or development of a condition with high risk of progression to AVB. There are insufficient data regarding long-term follow-up on pacing dependency. From February 2009 to July 2011, 191 transcatheter aortic valve implantation procedures were performed at the Rabin Medical Center (125 CoreValve and 66 Edwards SAPIEN). Thirty-two patients (16.7%) received a PPM (30 with CoreValve and 2 with Edwards SAPIEN). Data from the pacemaker clinic follow-up was available in 27 patients. After a mean follow-up of 52 weeks (range, 22 to 103), only 8 (29%) of 27 patients were pacing dependent. The indication of PPM in these 8 patients was complete AVB. In conclusion, in our center, the rate of PPM implantation was 16%, which is lower than that reported in the published works. Only 29% of those patients implanted with PPM were pacemaker dependent. Further studies are necessary to define reliable predictors for long-term pacing.

  • Research article

    (Video) Teach the Teacher Workshop: Awake Flexible Fiberoptic Intubation- How to Perform an Awake Intubation

    Airway support using a pediatric intubation tube in adult patients with atrial fibrillation: A simple and unique method to prevent heart movement during catheter ablation under continuous deep sedation

    Journal of Arrhythmia, Volume 33, Issue 4, 2017, pp. 262-268

    The present study aimed to elucidate the safety and effectiveness of a noble and unique airway management technique in which a pediatric intubation tube is used in adult patients with atrial fibrillation (AF) undergoing catheter ablation (CA) under continuous deep sedation.

    In total, 246 consecutive patients with AF (mean age, 65±10 years; 60 women) underwent CA under dexmedetomidine-based continuous deep sedation. A 4-mm pediatric intubation tube guided by a 10-French intratracheal suction tube was inserted smoothly, and the tip of the tube was located at the base of the epiglottis. The maximum shifting distance of the heart (MSDH) was measured with the 3D mapping system (Ensite NavX system) before and after inserting the pediatric intubation tube.

    At baseline, the MSDH of patients under continuous deep sedation was 23±14mm. The pediatric intubation tube reduced the MSDH to 13±6mm (mean reduction from baseline, 38.4±21.7%; P<0.0001). In contrast, oxygen saturation was significantly increased from 89±8% to 95±3% (P<0.0001). The mean distance between the nostril and base of the epiglottis was 16.6±0.5mm. Major periprocedural complications occurred in 9 (3.6%) patients including 3 (1.2%) cardiac tamponade and 6 (2.4%) phrenic nerve injury cases. Larger MSDH (odds ratio, 1.13; 95% confidence interval, 1.04–1.25; P=0.007) was a significant predictor of major periprocedural complications. No major airway complications occurred, except in 3 patients (1.2%) who had minor nasal bleeding.

    This unique airway management technique using a pediatric intubation tube for CA procedures performed in adult patients with AF under continuous deep sedation was easy, safe, and effective.

  • Research article

    Rebound tonometry over an air-filled anterior chamber in the supine child after intraocular surgery

    Journal of American Association for Pediatric Ophthalmology and Strabismus, Volume 20, Issue 2, 2016, pp. 159-164

    Intracameral air is a critical component of multiple ophthalmic surgical procedures and is frequently used in pediatric intraocular surgery. Among other benefits, it helps to facilitate postoperative examination in uncooperative children by allowing quick confirmation of a formed anterior chamber. The purpose of this study was to evaluate the usefulness and accuracy of a position-independent rebound tonometer (Icare PRO) in measuring intraocular pressure (IOP) intraoperatively in pediatric eyes with intracameral air compared to a commonly used handheld applanation tonometer (Tono-Pen XL).

    In this prospective study of sequential children undergoing intraocular surgery, IOP was measured immediately following general anesthesia induction using both Icare PRO rebound tonometry and Tono-Pen XL tonometry, with instrument order randomized, in the supine child's eye(s). At completion of surgery after standard placement of intracameral air IOP was again measured using both instruments.

    A total of 42 eyes of 30 children were included. Surgeries included glaucoma (25), cataract-related (16), and both (1). Mean preoperative IOP by Tono-Pen XL was 23.52±9.76mm Hg; by Icare PRO, 20.94±10.01mm Hg (P=0.0012). Mean IOP over intracameral air at surgery conclusion by Tono-Pen XL (n=41) was 12.66±4.90; by Icare PRO (n=42), 12.96±5.10mm Hg (P=0.46). One eye had postoperative IOP unrecordable by Tono-Pen XL but 7.9mm Hg by Icare PRO. Bland-Altman analysis, which included only paired measurements, showed a preoperative mean difference in IOP (ΔIOPT−I) of 2.58mm Hg (95% CI, −6.86 to 12.02); postoperative mean ΔIOPT−I of −0.42mm Hg [95% CI, −7.57 to 6.73].

    Position-independent rebound tonometry (Icare PRO) accurately measured IOP in supine children's eyes postoperatively in the presence of intracameral air.

Copyright © 1990 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.


1. CoreEM: Fiberoptic Intubation
(Core EM)
2. Assisting During Intubation
(American Nurses Association)
3. Fiberoptic Intubation Skills - Basic Movements for Intubation Success
(The Protected Airway Collaborative)
4. Teach the Teacher Workshop: Awake Flexible Fiberoptic Intubation
5. NAP4 Fibreoptic Intubation
(Royal College of Anaesthetists)
6. Fiberoptic intubation through an i-gel
(MedStar Emergency Physicians)
Top Articles
Latest Posts
Article information

Author: Prof. Nancy Dach

Last Updated: 19/05/2023

Views: 6651

Rating: 4.7 / 5 (77 voted)

Reviews: 84% of readers found this page helpful

Author information

Name: Prof. Nancy Dach

Birthday: 1993-08-23

Address: 569 Waelchi Ports, South Blainebury, LA 11589

Phone: +9958996486049

Job: Sales Manager

Hobby: Web surfing, Scuba diving, Mountaineering, Writing, Sailing, Dance, Blacksmithing

Introduction: My name is Prof. Nancy Dach, I am a lively, joyous, courageous, lovely, tender, charming, open person who loves writing and wants to share my knowledge and understanding with you.