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Anesthesiology:
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UNDO Your Troubles with the Tube: How to Improve Your Success with Endotracheal Tube Passage during Fiberoptic Intubation

Wheeler, Melissa M.D.*; Dsida, Richard M. M.D.

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To the Editor:—

The article by Johnsen et al.1 once again highlights a problem commonly faced by practitioners using a fiberoptic scope to intubate the trachea, i.e., resistance to passage of the endotracheal tube. As they discuss, this is usually attributed to the endotracheal tube being caught on structures of the supraglottic airway.2–6 Johnson et al. correctly report that when oral fiberoptic intubation is attempted, the most common cause of obstruction to endotracheal tube placement is the right arytenoid cartilage. The article that best describes the anatomical reasons for endotracheal tube obstruction is based on observation of obstruction to endotracheal tube placement in an intubating mannequin.3 Unfortunately, Johnson et al. neglect to credit this investigation, which found the same cause of obstruction, albeit not in human subjects, as they now report. In addition, as we reported in a letter to the editor of this journal, we have had years of experience with a high degree of successful oral endotracheal tube passage over the fiberscope in children and adults using the method of beginning with the bevel in the down position or facing posteriorly.7 For example, in one of our recent publications examining the best method to teach fiberoptic intubation to residents, we found a high degree of successful initial endotracheal tube passage over the fiberscope. By paying strict attention to bevel orientation, we had only 3 failures of 300 intubation attempts that were secondary to inability to pass the endotracheal tube.8 Overall, intubation was successful in 292 of 300 attempts; the 5 additional failures were secondary to being unable to correctly place the fiberscope.8 This is a far higher success rate than the 50% obstruction Johnson et al. report when the bevel orientation is not down or posterior. It should also be noted that anatomical obstruction for nasal intubation differs.3 In this case, obstruction is usually secondary to the epiglottis, and, as we have advocated and continue to teach, when nasal intubation is performed, the bevel orientation should be up or facing anteriorly to assure the highest rate of successful endotracheal tube passage. An easy mnemonic to assist in remembering the endotracheal tube orientation is “UNDO your troubles with the tube”—i.e., bevel Up for Nasal fiberoptic intubation and bevel Down for Oral fiberoptic intubation.
Melissa Wheeler, M.D.,*
Richard M. Dsida, M.D.
*Feinberg School of Medicine, Northwestern University, Chicago, Illinois. melissa-wheeler@msn.com
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References

1. Johnson DM, From AM, Smith RB, From RP, Maktabi MA: Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation. Anesthesiology 2005; 102:910–4

2. Ovassapian A, Yelich SJ, Dykes MH, Brunner EE: Fiberoptic nasotracheal intubation: Incidence and causes of failure. Anesth Analg 1983; 62:692–5

3. Katsnelson T, Frost EA, Farcon E, Goldiner PL: When the endotracheal tube will not pass over the flexible fiberoptic bronchoscope. Anesthesiology 1992; 76:151–2

4. Kristensen MS: The Parker Flex-Tip tube versus a standard tube for fiberoptic orotracheal intubation: A randomized double-blind study. Anesthesiology 2003; 98:354–8

5. Schwartz D, Johnson C, Roberts J: A maneuver to facilitate flexible fiberoptic intubation. Anesthesiology 1989; 71:470–1

6. Jones HE, Pearce AC, Moore P: Fibreoptic intubation: Influence of tracheal tube tip design. Anaesthesia 1993; 48:672–4

7. Wheeler M, Dsida RM: Fiberoptic intubation: Troubles with the “tube.” Anesthesiology 2003; 99:1236–7

8. Wheeler M, Roth AG, Dsida RM, Rae B, Seshadri R, Sullivan CL, Heffner CL, Cote CJ: Teaching residents pediatric fiberoptic intubation of the trachea: Traditional fiberscope with an eyepiece versus a video-assisted technique using a fiberscope with an integrated camera. Anesthesiology 2004; 101:842–6

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