This work is funded by the department of anesthesiology at children's hospital of Michigan.

1. Equipment Preparation
<ol>
	<li>Med fusion pump for propofol infusion</li>
	<li>Place nasotracheal tubes under heating mattress</li>
	<li>Connect camera to scope and check orientation</li>
	<li>Three movements affect the view through the scope:
		<ol>
			<li>In and out.</li>
			<li>Rotation using a two-handed maneuver.</li>
			<li>Flexion and extension of the tip of the scope.</li>
		</ol>
	</li>
</ol>
2. Additional Equipment
<ol>
	<li>Fentanyl 0.5-1.0 mcg/kg </li>
	<li>12F red rubber suction catheter</li>
	<li>Glycopyrrolate 0.1-0.2 mg </li>
	<li>Metal insufflation hook</li>
	<li>Afrin nasal spray </li>
	<li>Lubricant</li>
	<li>Lidocaine 2% or 4% for spraying nares</li>
</ol>
3. Patient Preparation
<ol>
	<li>Perform mask induction maintaining spontaneous ventilation.</li>
	<li>Start IV and give fentanyl and glycopyrrolate IV.</li>
	<li>Give propofol bolus 1 mg/kg and begin propofol infusion 200 mcg/kg/min.</li>
	<li>Tape eyes before spraying Afrin to avoid dilation of pupils.</li>
	<li>Spray Afrin and lidocaine in both nares.</li>
	<li>Mask ventilate the patient to distribute Afrin and lidocaine distally.</li>
	<li>Pass red rubber catheter into both nares to check patency.</li>
	<li>Choose the more patent nostril for the fiberoptic scope.</li>
	<li>Keep the red rubber in the other nostril with tip in the hypopharynx for O2.</li>
	<li>Use insufflation hook to connect red rubber to the circuit and administer 2 L/min of O2 (don't insufflate high flows into the hypopharynx).</li>
</ol>
4. Actual Fiberoptic Intubation
<ol>
	<li>Take connector off the nasotracheal tube.</li>
	<li>Advance tube all the way up the lubricated fiberoptic scope.</li>
	<li>Clean fiberoptic tip with alcohol</li>
	<li>Put a slight curve on the end of the scope to follow the floor of the nose.</li>
	<li>Thread the fiberoptic to the larynx blindly.</li>
	<li>Look for any recognizable anatomic structures. FREEZE!</li>
	<li>Bring anatomic structures into the center of the field and keep them there.</li>
	<li>When approaching the vocal cords, give a bolus of propofol 1 mg/kg IV.</li>
	<li>Once through the cords, make a downward turn into the trachea.</li>
	<li>Follow tracheal rings to the level of the carina.</li>
	<li>You may require an additional propofol bolus of 1 mg/kg IV.</li>
	<li>Make sure the fiberoptic scope tip is in a neutral position.</li>
	<li>Thread the ETT. If the ETT gets hung up at the larynx, give a 360&deg; turn of the tube to spin it into the trachea.</li>
</ol>
5. Representative Results
This video shows an efficient technique for elective fiberoptic intubation in pediatric patients that is easily teachable to residents and fellows and reproducible. The main key is to maintain spontaneous ventilation at all times. Good equipment preparation before hand is also important.

<ol>
	<li>Kinouchi, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+difficult+pediatric+airway.">Management of difficult pediatric airway.</a> Masui. 55, 24-32 (2006).</li><li>Chen, Y. L., Wu, K. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Airway+management+of+patients+with+craniofacial+abnormalities:+10-year+experience+at+a+teaching+hospital+in+Taiwan.">Airway management of patients with craniofacial abnormalities: 10-year experience at a teaching hospital in Taiwan.</a> J Chin Med Assoc. 72, 468-470 (2009).</li><li>. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Practice+guidelines+for+management+of+the+difficult+airway:+an+updated+report+by+the+American+Society+of+Anesthesiologists+Task+Force+on+Management+of+the+Difficult+Airway.">Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.</a> Anesthesiology. 98, 1269-1277 (2003).</li><li>Fiadjoe, J., Stricker, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pediatric+difficult+airway+management:+current+devices+and+techniques.">Pediatric difficult airway management: current devices and techniques.</a> Anesthesiol Clin. 27, 185-195 (2009).</li><li>Wheeler, M., Roth, A. G., Dsida, R. M., Rae, B., Seshadri, R., Sullivan, C. L., Heffner, C. L., Cote, C. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=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.">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.</a> Anesthesiology. 101, 842-846 (2004).</li><li>Roth, A. G., Wheeler, M., Stevenson, G. W., Hall, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+a+rigid+laryngoscope+with+the+ultrathin+fibreoptic+laryngoscope+for+tracheal+intubation+in+infants.">Comparison of a rigid laryngoscope with the ultrathin fibreoptic laryngoscope for tracheal intubation in infants.</a> Can J Anaesth. 41, 1069-1073 (1994).</li><li>Ovassapian, A., Dykes, M. H., Golmon, M. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+training+programme+for+fibreoptic+nasotracheal+intubation.+Use+of+model+and+live+patients.">A training programme for fibreoptic nasotracheal intubation. Use of model and live patients.</a> Anaesthesia. 38, 795-798 (1983).</li><li>Stevenson, G. W., Roth, A. G., Wheeler, M., Hall, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+the+Olympus+LF-P+fibreoptic+laryngoscope+by+trainees+in+paediatric+anaesthesia.">Use of the Olympus LF-P fibreoptic laryngoscope by trainees in paediatric anaesthesia.</a> Anaesthesia. 51, (1996).</li><li>Taguchi, S., Kusunoki, S., Fukuda, H., Hamada, H., Kawamoto, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Difficult+tracheal+intubation+using+airway+scope+in+a+pediatric+patient+with+Hunter+syndrome.">Difficult tracheal intubation using airway scope in a pediatric patient with Hunter syndrome.</a> Masui. 58, 1278-1281 (2009).</li></ol>

No conflicts of interest declared.

Fiberoptic intubation in pediatric patients with difficult airway could be a challenging task1,2 and the presence of craniofacial dysmorphisms presents additional challenges to tracheal intubation3. It is more difficult to perform this procedure in pediatric patients than in adults mainly because of smaller airways in pediatric patients which make the manipulation of the fiberoptic more difficult since any small movement of the tip of the firberoptic scope runs the risk of touching the mucosa of the...

<ul>
	<li>Med fusion pump for propofol infusion</li>
	<li>Fentanyl 0.5-1.0 mcg/kg</li>
	<li>12F red rubber suction catheter</li>
	<li>Glycopyrrolate 0.1-0.2 mg</li>
	<li>Metal insufflation hook</li>
	<li>Afrin nasal spray</li>
	<li>Lubricant</li>
	<li>Lidocaine 2% or 4% for spraying nares</li>
</ul>

guidelines for elective pediatric fiberoptic intubation

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small babies will desaturate very quickly if ventilation is interrupted mainly to high metabolic rate. We describe guidelines to perform a safe fiberoptic intubation while maintaining spontaneous breathing throughout the procedure. Steps requiring the use of propofol pump, fentanyl, glycopyrrolate, red rubber catheter, metal insuflation hook, afrin, lubricant and lidocaine spray are shown.

Watch this Scientific Journal Video about Guidelines for Elective Pediatric Fiberoptic Intubation at JoVE.com

Guidelines for Elective Pediatric Fiberoptic Intubation

We describe guidelines to perform a safe and efficient elective fiberoptic intubation in pediatric patients while maintaining spontaneous ventilation.

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small ...

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17.3K Views.  St. Jude Children's Research Hospital. We describe guidelines to perform a safe and efficient elective fiberoptic intubation in pediatric patients while maintaining spontaneous ventilation.

Video: Guidelines for Elective Pediatric Fiberoptic Intubation

A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit.
Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.
A 13 year old patient was taken to the operating room for incision and drainage of a neck abcess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

We describe a technique to maintain oxygenation and ventilation using an endotracheal tube inserted nasally to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which ...

Endotracheal Intubation in Mice via Direct Laryngoscopy Using an Otoscope

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Endotracheal Intubation in Mice via Direct Laryngoscopy Using an Otoscope

We have developed a simple, reliable, and relatively inexpensive method for endotracheal intubation in mice via direct laryngoscopy using an otoscope with a 2.0 mm speculum. This technique is atraumatic and can be used for repeated measurements in chronic experiments. We find it superior to tracheostomy or previously reported nonsurgical techniques.

Mice, both wildtype and transgenic, are the principal mammalian model in biomedical research currently. Intubation and mechanical ventilation are ...

A Simple Method of Mouse Lung Intubation

A simple procedure to intubate mice for pulmonary function measurements would have several advantages in longitudinal studies with limited numbers or expensive animal. One of the reasons that this is not done more routinely is that it is relatively difficult, despite there being several published studies that describe ways to achieve it. In this paper we demonstrate a procedure that eliminates one of the major hurdles associated with this intubation, that of visualizing the trachea during the entire time of intubation. The approach uses a 0.5 mm fiberoptic light source that serves as an introducer to direct the intubation cannula into the mouse trachea. We show that it is possible to use this procedure to measure lung mechanics in individual mice over a time course of at least several weeks. The technique can be set up with relatively little expense and expertise, and it can be routinely accomplished with relatively little training. This should make it possible for any laboratory to routinely carry out this intubation, thereby allowing longitudinal studies in individual mice, thereby minimizing the number of mice needed and increasing the statistical power by using each mouse as its own control.

This paper describes a striaghforward and efficient method of intubating mice for pulmonary function measurements or pulmonary instillation, that allows the mice to recover and be studied at later times. The procedure involves an inexpensive fiberoptic light source that directly illuminates the trachea.

A  simple procedure to intubate mice for pulmonary function measurements would  have several advantages in longitudinal studies with limited numbers or  ...

Intubation-mediated Intratracheal (IMIT) Instillation: A Noninvasive, Lung-specific Delivery System

Respiratory disease studies typically involve the use of murine models as surrogate systems. However, there are significant physiologic differences between the murine and human respiratory systems, especially in their upper respiratory tracts (URT). In some models, these differences in the murine nasal cavity can have a significant impact on disease progression and presentation in the lower respiratory tract (LRT) when using intranasal instillation techniques, potentially limiting the usefulness of the mouse model to study these diseases. For these reasons, it would be advantageous to develop a technique to instill bacteria directly into the mouse lungs in order to study LRT disease in the absence of involvement of the URT. We have termed this lung specific delivery technique intubation-mediated intratracheal (IMIT) instillation. This noninvasive technique minimizes the potential for instillation into the bloodstream, which can occur during more invasive traditional surgical intratracheal infection approaches, and limits the possibility of incidental digestive tract delivery. IMIT is a two-step process in which mice are first intubated, with an intermediate step to ensure correct catheter placement into the trachea, followed by insertion of a blunt needle into the catheter to mediate direct delivery of bacteria into the lung. This approach facilitates a &#62;98% efficacy of delivery into the lungs with excellent distribution of reagent throughout the lung. Thus, IMIT represents a novel approach to study LRT disease and therapeutic delivery directly into the lung, improving upon the ability to use mice as surrogates to study human respiratory disease. Furthermore, the accuracy and reproducibility of this delivery system also makes it amenable to Good Laboratory Practice Standards (GLPS), as well as delivery of a wide range of reagents which require high efficiency delivery to the lung.

Intubation-mediated Intratracheal IMIT Instillation: A Noninvasive, Lung-specific Delivery System

Intubation-mediated intratracheal (IMIT) instillation of reagents is an excellent, noninvasive method for studying respiratory disease, as well as a method for instilling therapeutic reagents directly into the lung. It is a rapid and highly reproducible method which is suitable for preclinical testing.

Respiratory disease studies typically involve the use of murine models as surrogate systems. However, there are significant physiologic differences ...

An Improved Method for Rapid Intubation of the Trachea in Mice

Despite some anatomical and physiological differences, mouse models continue to be an essential tool for studying human lung disease. Bleomycin toxicity is a commonly used model to study both acute lung injury and fibrosis, and multiple methods have been developed for administering bleomycin (and other toxic agents) into the lungs. However, many of these approaches, such as transtracheal instillation, have inherent drawbacks, including the need for strong anesthetics and survival surgery. This paper reports a quick, reproducible method of intratracheal intubation that involves mild inhaled anesthesia, visualization of the trachea, and the use of a surrogate spirometer to confirm exposure. As a proof of concept, 8-12 week old C57BL/6 mice were administered either 2.0 U/kg of bleomycin or an equivalent volume of PBS, and both damage and fibrotic endpoints were measured post-exposure. This procedure allows researchers to treat a large cohort of mice in a relatively short period with little expense and minimal post-procedure care.

This article presents a rapid and simple method for administering bleomycin directly into the mouse trachea via intubation. Key advantages of this method are that it is highly reproducible, easy to master, and does not require specialized equipment or lengthy recovery times.

Despite some anatomical and physiological differences, mouse models continue to be an essential tool for studying human lung disease. Bleomycin toxicity ...

Interictal High Frequency Oscillations Detected with Simultaneous Magnetoencephalography and Electroencephalography as Biomarker of Pediatric Epilepsy

Crucial to the success of epilepsy surgery is the availability of a robust biomarker that identifies the Epileptogenic Zone (EZ). High Frequency Oscillations (HFOs) have emerged as potential presurgical biomarkers for the identification of the EZ in addition to Interictal Epileptiform Discharges (IEDs) and ictal activity. Although they are promising to localize the EZ, they are not yet suited for the diagnosis or monitoring of epilepsy in clinical practice. Primary barriers remain: the lack of a formal and global definition for HFOs; the consequent heterogeneity of methodological approaches used for their study; and the practical difficulties to detect and localize them noninvasively from scalp recordings. Here, we present a methodology for the recording, detection, and localization of interictal HFOs from pediatric patients with refractory epilepsy. We report representative data of HFOs detected noninvasively from interictal scalp EEG and MEG from two children undergoing surgery.
The underlying generators of HFOs were localized by solving the inverse problem and their localization was compared to the Seizure Onset Zone (SOZ) as this was defined by the epileptologists. For both patients, Interictal Epileptogenic Discharges (IEDs) and HFOs were localized with source imaging at concordant locations. For one patient, intracranial EEG (iEEG) data were also available. For this patient, we found that the HFOs localization was concordant between noninvasive and invasive methods. The comparison of iEEG with the results from scalp recordings served to validate these findings. To our best knowledge, this is the first study that presents the source localization of scalp HFOs from simultaneous EEG and MEG recordings comparing the results with invasive recordings. These findings suggest that HFOs can be reliably detected and localized noninvasively with scalp EEG and MEG. We conclude that the noninvasive localization of interictal HFOs could significantly improve the presurgical evaluation for pediatric patients with epilepsy.

High Frequency Oscillations (HFOs) have emerged as presurgical biomarkers for the identification of the epileptogenic zone in pediatric patients with medically refractory epilepsy. A methodology for the noninvasive recording, detection, and localization of HFOs with simultaneous scalp electroencephalography (EEG) and magnetoencephalography (MEG) is presented.

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Protocol and Guidelines for Point-of-Care Lung Ultrasound in Diagnosing Neonatal Pulmonary Diseases Based on International Expert Consensus

Ultrasound is a safe bedside imaging tool that obviates the use of ionizing radiation diagnostic procedures. Due to its convenience, the lung ultrasound has received increasing attention from neonatal physicians. Nevertheless, clear reference standards and guideline limits are needed for accurate application of this diagnostic modality. This document aims to summarize expert opinions and to provide precise guidance to help facilitate the use of the lung ultrasound in the diagnosis of neonatal lung diseases.

Lung ultrasound is a noninvasive and valuable tool for bedside evaluation of neonatal lung diseases. However, a relative lack of reference standards, protocols and guidelines may limit its application. Here, we aim to develop a standardized neonatal lung ultrasound diagnostic protocol to be used in clinical decision-making.

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Repeated Orotracheal Intubation in Mice

The literature describes several methods for mouse intubation that either require visualization of the glottis through the oral cavity or incision in the ventral neck for direct confirmation of cannula placement in the trachea. The relative difficulty or the tissue trauma induced to the subject by such procedures can be an impediment to an investigator&#8217;s ability to perform longitudinal studies. This article illustrates a technique in which physical manipulation of the mouse following the use of a depilatory to remove hair from the ventral neck permits transcutaneous visualization of the trachea for orotracheal intubation regardless of degree of skin pigmentation. This method is innocuous to the subject and easily achieved with a limited understanding of murine anatomy. This refined approach facilitates repeated intubation, which may be necessary for monitoring progression of disease or instillation of treatments. Using this method may result in a reduction of the number of animals and technical skill required to measure lung function in mouse models of respiratory disease.

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The use of pigs in research has increased in recent years. Nevertheless, pigs are characterized by difficult airway anatomy. By demonstrating how to perform endoscopically guided endotracheal intubation, the present protocol aims to further increase laboratory animals' safety to avoid animal suffering and unnecessary death.

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