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Correspondence  |   November 2003
Fiberoptic Intubation: Troubles with the “Tube”?
Author Affiliations & Notes
  • Melissa Wheeler, M.D.
    *
  • *Children's Memorial Hospital, Chicago, Illinois.
Article Information
Correspondence
Correspondence   |   November 2003
Fiberoptic Intubation: Troubles with the “Tube”?
Anesthesiology 11 2003, Vol.99, 1236-1237. doi:
Anesthesiology 11 2003, Vol.99, 1236-1237. doi:
To the Editor:—
The article by Dr. Kristensen highlights a problem often faced by practitioners when using a fiberoptic scope to intubate the trachea, i.e.  , resistance to passage of the endotracheal tube. 1 This is usually attributed to the endotracheal tube being caught on structures of the supraglottic airway. 2–4 We are curious to know how the bevel of the endotracheal tube was oriented as it was passed over the scope into the trachea. Dr. Kristensen states, “the tube was mounted onto the fiberscope with the concavity of the curvature facing the side of the maneuver lever.” We are unsure how this translates to the orientation of the bevel and the Murphy tip of the endotracheal tube, relative to the tip of the fiberoptic scope, and whether this relationship was maintained during passage of the endotracheal tube. In our experience, this orientation of the leading edge bevel is the most important determinant of successful passage of the endotracheal tube. The author's figure 1does little to clarify what the initial orientation of the bevel was and whether or not it was the same for both types of endotracheal tubes that he studied. The 90-degree counterclockwise rotation of the endotracheal tube described by Dr. Kristensen as the first maneuver to improve passage after initial failure has been advocated by others. 2,3,5 This was originally proposed to change the “usual” orientation of the endotracheal tube, i.e.  , the bevel facing left  , to an orientation in which the bevel is facing down  2 (fig. 1). This bevel-down orientation appears to improve the success of oral fiberoptic tracheal intubation by allowing the endotracheal tube to slip past the potentially obstructing right arytenoid cartilage. 3 If nasal intubation is used, the endotracheal tube should be turned 90 degrees clockwise from its usual orientation so that the bevel is facing up  , thus avoiding the epiglottis. 3 In our practice, we begin with the endotracheal tube oriented bevel-down for oral fiberoptic intubations and bevel-up for nasal fiberoptic intubations. These simple maneuvers reduce the first-attempt failure rate for passage of the endotracheal tube into the trachea. Close reading of one of the first investigations into improving passage of the endotracheal tube during fiberoptic intubation reveals that successful oral intubation was achieved in 9 of 11 patients after initial failure when the bevel orientation was changed as we describe. 5 We have found this technique of beginning with the bevel in the optimal orientation to be useful for standard polyvinyl chloride endotracheal tubes, straight and preformed Ring Adair Elwyn, i.e.  , RAE (nasal and oral). Thus, special endotracheal tubes, which have an increased cost and may not be available in small sizes, may not be needed to improve the success rate of fiberoptic intubation.
Fig. 1. The endotracheal tube marked A  is positioned with the bevel down  , as recommended for orotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the right arytenoid cartilage. The endotracheal tube marked B  is the usual bevel orientation (bevel left  ) used during rigid laryngoscopy and intubation. The endotracheal tube marked C  is positioned with the bevel up  , as recommended for nasotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the epiglottis.
Fig. 1. The endotracheal tube marked A 
	is positioned with the bevel down 
	, as recommended for orotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the right arytenoid cartilage. The endotracheal tube marked B 
	is the usual bevel orientation (bevel left 
	) used during rigid laryngoscopy and intubation. The endotracheal tube marked C 
	is positioned with the bevel up 
	, as recommended for nasotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the epiglottis.
Fig. 1. The endotracheal tube marked A  is positioned with the bevel down  , as recommended for orotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the right arytenoid cartilage. The endotracheal tube marked B  is the usual bevel orientation (bevel left  ) used during rigid laryngoscopy and intubation. The endotracheal tube marked C  is positioned with the bevel up  , as recommended for nasotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the epiglottis.
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References
Kristensen MS: The Parker Flex-Tip tube versus  a standard tube for fiberoptic orotracheal intubation: A randomized double- blind study. A nesthesiology 2003; 98: 354–8Kristensen, MS
Schwartz D, Johnson C, Roberts J: A maneuver to facilitate flexible fiberoptic intubation. A nesthesiology 1989; 71: 470–1Schwartz, D Johnson, C Roberts, J
Katsnelson T, Frost CAM, Farcon E, Goldiner PL: When the endotracheal tube will not pass over the flexible fiberoptic bronchoscope. A nesthesiology 1992; 76: 151–2Katsnelson, T Frost, CAM Farcon, E Goldiner, PL
Ovassapian A, Yellich J, Dykes MHM, Brunner EE: Fiberoptic nasotracheal intubation: Incidents and causes of failure. Anesth Analg 1983; 62: 692–5Ovassapian, A Yellich, J Dykes, MHM Brunner, EE
Jones HE, Pearce AC, Moore P: Fibreoptic intubation: Influence of tracheal tube tip design. Anaesthesia 1993; 48: 672–4Jones, HE Pearce, AC Moore, P
Fig. 1. The endotracheal tube marked A  is positioned with the bevel down  , as recommended for orotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the right arytenoid cartilage. The endotracheal tube marked B  is the usual bevel orientation (bevel left  ) used during rigid laryngoscopy and intubation. The endotracheal tube marked C  is positioned with the bevel up  , as recommended for nasotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the epiglottis.
Fig. 1. The endotracheal tube marked A 
	is positioned with the bevel down 
	, as recommended for orotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the right arytenoid cartilage. The endotracheal tube marked B 
	is the usual bevel orientation (bevel left 
	) used during rigid laryngoscopy and intubation. The endotracheal tube marked C 
	is positioned with the bevel up 
	, as recommended for nasotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the epiglottis.
Fig. 1. The endotracheal tube marked A  is positioned with the bevel down  , as recommended for orotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the right arytenoid cartilage. The endotracheal tube marked B  is the usual bevel orientation (bevel left  ) used during rigid laryngoscopy and intubation. The endotracheal tube marked C  is positioned with the bevel up  , as recommended for nasotracheal fiberoptic intubation to prevent obstruction to endotracheal tube passage by the epiglottis.
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