• hold FOB with left hand with pen-grip (better than underhand grip)
• measure the distance from nares to cord (use FOB)
  • insert FOB into nasal passage until this distance, and cords should be on view
  • avoids going too far and hitting pharyngeal wall
  • avoids not going far enough and getting lost in nasal turbinates
• use visual cueing
  • small manipulations of the FOB, and use these to orientate which is up/down/left/right
  • instead of trying to remember which way is which (especially because it is reversed when standing in front of patient)
• Venn diagram
  • people needing a FOB vs people received a FOB
  • the intersection = safe
  • left = unnecessary FOB
  • right = trouble = needing FOB but didn't
• Suction catheter oxygenation
  • pass down contralateral nostril to FOB
  • connect O2 from Common Gas Outlet (take off from T-piece)
• Rail-roading
  • requires a SNUG fit between introducer and ETT
  • eg. 3.8 mm AmbuScope + DLT at 1 size smaller
• Keep it simple, these are the most effective methods
  • the nasal route is usually easiest, caution turbinate trauma
  • asleep LMA / iLMA
• Always test tube + FOB fit together
• Clean lens with Alcowipe

• bronchial lavage
  • clear secretions
  • go up to 3rd/4th generation airways
  • use NS, not water
    • this would be akin to freshwater drowning with large amounts of lavage
    • causes fluid shifts, best to use isotonic lavage
  • use warmed water, to ⬇risk bronchospasm
  • 20-60 mL x5 = max 300 mL

• Nasal
  • Epistaxis
    • This is significant, will transform situation into a difficult airway
    • Reserve for where oral intubation is CIN

• Prefer patient bed
  • Superior sitting up
  • Wider, more stable
• Stand in front of patient on their right
  • This simulates a true emergent need for AFOI
  • Screen on the patient's left, better line of vision

• Use NPA

• Get past tongue

  • Go straight past = measure first
  • Berman
  • Patient to poke tongue out
  • Assistant to pull tongue forward with gauze
  • Assistant to provide jaw thrust = widens view by ~ 30%

• Navigate oropharynx

  • Don't touch the walls, this will create cough
  • Tongue protrusion (patient / assistant)

• Navigate trachea

• Check depth

  • Tip of FOB at carina
  • Withdraw to appearance of ETT tip
  • Adjust ETT as necessary

• AmbuScope aScope
  • Slim = Gray = 3.8 mm
    • Most comfortable
    • Less rigidity
  • Regular = Green = 5.0 mm
  • Large = Orange = 5.8 mm
    • This will be tight with a 6.5 tube
• Storz
  • 5.9 mm = ideal
  • 4.0 mm = too big for DLT
  • 2.8 mm
    • no suction
    • no wire
    • can't railroad ETT = too flexible
• Can use ureteroscope + Stryker tower
  • This is the narrowest scope

• Bill Bestic
• Chris Sparks

https://www.ncbi.nlm.nih.gov/books/NBK430762/