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Consider the following case: A 54-year-old female with a multinodular goiter is scheduled for thyroidectomy. She has a history of non-insulin-dependent diabetes, obstructive sleep apnea (OSA), and is morbidly obese with a body mass index (BMI) of 54 kg·m−2. She provides a history of difficult airway management at another institution 10 years previously at cholecystectomy, but unfortunately, these records are unavailable. Airway examination reveals a small mouth opening (3 cm or approximately 2 finger-breadths), full dentition with prominent upper incisors, and a receding mandible. When asked to protrude her lower mandible, she is unable to bite her upper lip with her lower incisors. Her neck extension is unremarkable but her neck is notably short and has a circumference of 44 cm. She has a Mallampati score of IV. As expected, her cricothyroid membrane (CTM) is difficult to identify.

This patient presents with multiple predictors of difficult face-mask ventilation, difficult direct laryngoscopy (DL), difficult video laryngoscopy (VL), difficult extraglottic device (EGD) use, and difficult front-of-neck airway (FONA).1 Additionally, she is scheduled for surgery in which avoiding tracheal intubation is not a practical option. Awake intubation using a flexible bronchoscope is an appropriate initial management plan, and alternative techniques including awake intubation using a video laryngoscope or an optical stylet can also be considered. Regardless of the method used, adequate regional anesthesia of the airway is a prerequisite for safe and successful intubation in the awake, cooperative patient.2

What Are the Fundamentals of an “Awake, Bronchoscopically Facilitated” Intubation?

Awake bronchoscopic intubation is a core skill set for awake management of a difficult airway. A practitioner requires a working knowledge of applied airway anatomy to aid in the targeted application of local anesthetics to anesthetize the airway (applied either topically or via nerve blocks of the airway), and adequate dexterity and experience to drive a flexible bronchoscope to successfully use this technique.


The upper airway functionally consists of four regions: the nasal cavities, the pharynx, the larynx, and the trachea (Figure 3.1).3 The mouth provides an additional route to the pharynx.


Sagittal view of the upper airway. (Reprinted with permission Cleveland Clinic Center for Medical Art & Photography ©2021. All Rights Reserved.)

The Nose

The nose has several functions including the facilitation of breathing, the humidification and filtering of inspired gases, the housing of the olfactory receptors, and the drainage of the paranasal sinuses and nasolacrimal ducts.3,4 The skeleton of the external nose is composed of bone superiorly and posteriorly, and cartilage inferiorly. The left and right nasal cavities are divided by the nasal septum in the midline and provide a conduit from the nares anteriorly to the posterior nasal aperture ...

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