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Time for a Fiberoptic Intubation?

An Expert Guide On How to Decide

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IntroductionWhich Patients
Right SituationCheck Ego at Door
The DecisionContraindications
FOI RescueLearning Space

1. Introduction

It seems counter-intuitive in the age of the video laryngoscope, but the fiberoptic approach to intubation is still considered the gold standard, even when the overwhelming majority of intubations today are performed with a laryngoscope. In spite of this, there are still specific situations in which a fiberoptic approach may be the best option. Here, we’ll spend some time getting to the bottom of that question, and give you a simple approach to help you decide if FOI is right in any clinical context.

2. The Big Picture

When You Want to Keep Them Breathing

In the big picture, fiberoptic intubation (FOI) at its most relevant when you want to keep your patient breathing because you’re concerned that the use of a paralytic agent (most commonly with RSI) might have adverse consequences. If your patient has a known or predicted anatomically difficult airway, and they are currently breathing on their own, the last thing you want to do is make the situation worse. This is where FOI shines, because it can be performed “awake” using light sedation and topicalization (something we will show you how to do later) allowing you to protect a patient’s respiratory drive.

The patients where this applies are most commonly those with known or predicted anatomically difficult airways in which the use of RSI might create a failed airway and/or a can’t intubate, can’t oxygenate situation (CICO). Here are some of the clinical scenarios for which this concern might apply 👇

indications for afoi

Check out this quick review of some of the clinical scenarios where an awake fiberoptic intubation (AFOI) might be indicated.

3. The Rest of the Story

Because Clinical Context Matters

Certainly a consideration for the use of AFOI in the known or predicted difficult airway makes sense, particularly in the patient undergoing an elective procedure, but this is not the whole picture. What if your patient is in extremis or unstable. What then? Is AFOI still a good choice. The second biggest factor in deciding whether FOI is right for your patient is: what are the TIME & CONDITIONS of situation. In other words, what is the context.

AFOI takes more time than RSI and you need to have certain favorable conditions to tip the scales in favor of it. In general emergent situations that require multiple rapid interventions make FOI a less viable option. Here are some things to consider:

4. One Last Question

How good are you? No, seriously…

As clinicians we must always take our ego out of the equation. If you only rarely use a fiberoptic device, or have not practiced regularly to keep your skills up, you should reconsider the FOI approach. Either call for help, or if there is no other option, stick to the technique you are most comfortable with.

Putting it all together
ask yourself these 3 questions

So how do you put this all together in the clinical setting? Use these three questions to help guide your decision, and help you make the right choice for your patient.

Contraindications to FOI

Sometimes FOI is a good idea, sometimes it’s not. Know when’s a good time to reconsider FOI use and when to do something else by watching here. 👀

FOI as a rescue device

Another great use for FOI is as a “plan B” rescue tool. In a failed intubation where a supraglottic airway device is placed and working, the use of a fiberoptic device to deliver a definitive airway through a SAD may be a good idea💡

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