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Learn Video Assisted Fiberoptic Intubation (VAFI)

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Video-Assisted Fiberoptic Intubation (VAFI)

Indication

Video-assisted Fiberoptic Intubation (VAFI) is indicated when traditional direct or video laryngoscopy is difficult or unsuccessful, particularly in patients with anticipated or encountered difficult airways. Specific indications include:

  • Restricted mouth opening (e.g., temporomandibular joint disorders, facial trauma, post-radiation fibrosis)
  • Distorted oropharyngeal anatomy (e.g., tumors, subglottic stenosis, or significant airway edema)
  • Limited neck mobility (e.g., cervical spine immobilization due to trauma or disease)
  • Failed direct or video laryngoscopy attempts
  • Patients requiring awake intubation due to high aspiration risk, airway swelling, or difficult airway anatomy

Benefits

  • Enhanced Visualization: Combines video laryngoscopy and fiberoptic bronchoscopy to optimize glottic visualization.
  • Improved Tube Delivery: Video laryngoscopy provides a pathway, while fiberoptic bronchoscopy guides the ETT into the trachea.
  • Increased First-Pass Success: Reduces airway trauma and repeated attempts, particularly in difficult cases.
  • Useful in Awake Intubation: This can be performed under topical anesthesia in cooperative patients.
  • Facilitates Team Coordination: The video screen allows Multiple providers to view the airway anatomy and intubation process.

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Step-by-Step Instructions for Performing VAFI

1. Preparation

Equipment Needed:

  • Video laryngoscope (e.g., Macintosh or hyperangulated blade)
  • Flexible fiberoptic bronchoscope (FOB)
  • Endotracheal tube (ETT) (appropriately sized, preloaded over the fiberoptic scope)
  • Suction setup
  • Oxygenation tools (nasal cannula, high-flow O2, or supraglottic airway if needed)
  • Lubricant for the fiberoptic scope
  • Sedation & Airway Management Medications (if required)
  • Local Anesthesia Supplies (if performing awake VAFI)

2. Patient Positioning

  • Standard “sniffing” position if possible.
  • If cervical spine precautions are needed, maintain neutral position with manual in-line stabilization (MILS).
  • Nasotracheal vs. Oral Approach: Choose based on clinical need.

3. Airway Preparation (If Awake)

  • Topicalize the airway with lidocaine spray (4%), nebulized lidocaine, or lidocaine-soaked gauze.
  • Consider glycopyrrolate to reduce secretions.
  • Light sedation (e.g., dexmedetomidine, remifentanil, or ketamine) may be used.

4. Video Laryngoscopy

  • Insert the video laryngoscope and obtain the best possible view of the glottis.
  • Optimize Blade Positioning: Avoid getting too close to the glottic opening, which could obscure the view.

5. Fiberoptic Scope Navigation

  • Preload the ETT onto the fiberoptic scope.
  • Insert the scope through the mouth (or nose, for nasal intubation).
  • Guide the fiberoptic scope toward the glottis under video laryngoscopic visualization.
  • Once the vocal cords and tracheal rings are seen, advance the fiberoptic scope into the trachea.

6. ETT Advancement

  • While stabilizing the fiberoptic scope, gently advance the ETT over the scope into the trachea.
  • Ensure correct placement by observing the carina or mainstem bronchi on the screen.

7. Confirmation of ETT Placement

  • Withdraw the fiberoptic scope while confirming the correct positioning of the ETT.
  • Use end-tidal CO₂ (capnography) and bilateral breath sounds to verify successful intubation.
  • Secure the tube and reassess ventilation.

Key Pearls & Troubleshooting

  • Fogging or Secretions? Use suction or warm the fiberoptic scope.
  • Difficult Scope Navigation? Adjust the patient’s head, use jaw thrust, or reposition the video laryngoscope.
  • ETT Gets Stuck? Rotate the tube 90° or adjust scope positioning.
  • Unable to Advance Scope? Consider a supraglottic airway as a conduit for fiberoptic scope placement.

The Bottom Line

Integrating video laryngoscopy and fiberoptic bronchoscopy, VAFI improves visualization, enhances tube guidance, and increases first-pass success rates, making it a valuable technique in managing difficult airways.

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Practice tools

Use the guided practice resources here to practice at your pace in a judgement-free zone. When you’re ready, visit one of our expert coaches for feedback on your technique.

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