What Are Video Laryngoscopy and Fiberoptic-Assisted Tracheal Intubation?

Video laryngoscopy allows for the larynx to be seen with a fiberoptic or digital laryngoscope inserted through the nose or mouth. Fiberoptic intubation inserts an ET tube over the shaft of a flexible fiberoptic scope for visualization.

Tracheal intubation, also called intubation, involves placing a flexible plastic tube (endotracheal [ET] tube) into the trachea (windpipe) to maintain an open airway, ventilate the lungs, or administer certain drugs. Video laryngoscopy and fiberoptic laryngoscope aid in tracheal intubation.

Video laryngoscopy is a form of indirect laryngoscopy in which the physician does not directly inspect the larynx. Instead, the larynx is visualized with a fiberoptic or digital laryngoscope (a camera with a light source) inserted transnasally (through the nose) or transorally (through the mouth).

Images and videos captured during video laryngoscopy can be displayed on a monitor for clinicians, patients, and others to view at the time of the procedure. It can also be recorded so it can be viewed at a later time. The images and video also help monitor disease progression and treatment. The images are magnified when displayed on the monitor, which helps in the detailed examination of the larynx. Video laryngoscopy forms the basis of fiberoptic intubation.

Fiberoptic intubation involves inserting an ET tube over the shaft of a flexible fiberoptic scope for visualization. Video laryngoscopy is also used with rigid transoral laryngoscopy. There are various variations to a rigid laryngoscope. The rigid laryngoscope can also be connected to a camera and monitor. 

Tracheal intubation is indicated as a medical procedure in various medical conditions that prevent a person from maintaining a clear airway, breathing, and oxygenating the blood. It is indicated in the following conditions:

• Inability to maintain an open airway
• Inability to protect the airway against aspiration
• Failure to ventilate
• Failure to oxygenate
• Lung and cardiac failure
• Provide general anesthesia, maintain the airway, and provide ventilation during surgery 

Indication for fiberoptic-assisted tracheal intubation:

• Any patient who meets the criteria for intubation can be intubated fiberoptically. However, because of equipment involved, most doctors use fiberoptic intubation for patients who have a difficult airway.

Patients with the following conditions or in the following categories are likely to have a difficult airway:

• Micrognathia (much smaller or shorter lower jaw than the rest of the face)
• Mandibular (jaw) fracture
• Partially obstructing laryngeal lesions such as tumors 
• Cervical (neck) spine injuries or cervical instability
• Rheumatoid arthritis or patients who are unable to extend the neck due to other conditions 
• A history of head and neck radiation therapy 
• Trismus (lockjaw)
• Craniofacial abnormalities (birth defects of the face and head)

Fiberoptic intubation is contraindicated in patients

• Who need a surgical airway (those with highly obstructing laryngeal lesions such as large tumors)
• With laryngeal trauma
• With craniofacial trauma who are actively bleeding into the oral cavity and throat

The procedure can be performed with the patient either awake or sedated. 

If the patient has a difficult airway, the procedure may be performed when they are awake using fiberoptic-assisted intubation. This is called awake intubation. 

In some circumstances, if the patient is anxious and unable to tolerate the procedure, they may be given mild intravenous sedation. For the awake patient, the procedure may be done with the patient seated or lying down, and local anesthesia would be provided to the nose and throat.

• Nasal intubation with general anesthesia: The technique of intubating nasally with the patient under general anesthesia is similar to that of awake intubation. After general anesthesia is induced, the patient is mask-ventilated in the supine position.
• Oral intubation with sedation: Oral intubation is usually performed with the patient sedated. The patient may also be sedated and kept spontaneously breathing. An oral airway often makes this easier and lifts the tongue off the posterior pharyngeal wall, facilitating exposure of the larynx. In oral intubation, the tongue can be grasped and lifted, providing better exposure, and hence, it is preferred.  
• Rigid video laryngoscopy: Several rigid laryngoscopes may be used for video laryngoscopy. The laryngoscope is attached to a camera and light source. Rigid laryngoscopy is usually performed under sedation.

• Equipment malfunction
• Trauma to the structures in the throat, vocal cords, trachea, or esophagus (food pipe)
• Spasm of the larynx