Fiberoptic oral intubation with flexible fiberoptic endoscope is a useful technique for establishing an airway in patients with abnormal upper airway anatomy, cervical immobilization, or awake intubations with preservation of the patient’s respiratory drive to when it is desirable to maintain spontaneously breathing during the intubation. Unlike endoscope or blind nasotracheal intubations, an oral approach can be more challenging because the scope must make a sharp turn in the posterior oropharynx before entering the hypopharynx. During nasotracheal intubation, the scope can make the turn in the nasopharynx and take a straight path towards the trachea.

It is key that patient is adequately anesthetized. Sedation with medications that allow spontaneous breathing and allow the patient to protected the airway are useful, avoiding deep sedation and paralytics as used in RSI. These can include ketamine, droperidol, dexmedetomidine, etc.

Oral Airways for Intubation

Since the patient is generally in an upright position, the tongue, mandible soft tissues can fall backwards obstructing the airway. This can make passage of the fiberoptic scope difficult. This can be improved with a jaw thrust, but is facilitated greatly by the use of a specialized intubating oral airway.

There are three available oral guides (bite protectors) including the Williams airway (shown below), Berman airway, and Ovassapian airway. They are all specifically designed for oral fiberoptic intubation to guide the fiberoptic scope and endotracheal tube around the oropharynx and keep the tongue and hypopharyngeal tissue from obstructing the trachea. The airways also protect the scope from being damaged if the patient bites down. The Williams airway comes in a 9cm “female” size and 10cm “male” size. Well lubricated, a 6.5 ETT can pass through either. Remember, after you have intubated, you must remove the 15mm adaptor to be able to remove it.

Williams Airway for Fiberoptic Oral Intubation

Equipment

  • Sedative medication
  • Fiberoptic scope (eg bronchoscope)
  • Lidocaine 4% cream and tongue blade
  • Lidocaine nebulization
  • Appropriately sized endotracheal tube
  • Williams airway
  • 10 mL syringe
  • Securing device for endotracheal tube
  • Capnography monitor / Colorimetric device
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