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CHAPTER 3: Preparation for Awake Intubation

Akua Gyambibi; Sree Kolli; M. Kwesi Kwofie

INTRODUCTION

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.

APPLIED AIRWAY ANATOMY

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.

FIGURE 3.1

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

An illustration presents the sagittal view of the upper airway. The different parts labeled are as follows. In front and above the almost triangular space above the mouth is the nasal septum. Inside the mouth is the fan-shaped muscle is the tongue. The tongue is attached to the bone in the front forming the lower jaw. Below the tongue is the vertical strip of structure epiglottis which covers the passage esophagus below. Attached to it is the hypo epiglottic ligament. Just below and in the front is two vertical structures in front of the esophagus the thyroid cartilage. Behind the esophagus is another narrow passage the trachea. Between the trachea and the esophagus is another vertical structure, the cricoid cartilage. Out of the bony structures and anteriorly is the large thyroid gland. At the back of the nose in the upper wall is the tissue pharyngeal tonsil. The nose continues to the passage behind the mouth. At the top of this passage is a Eustachian tube. This passage between the nose and mouth is the nasopharynx. The passage at the opening of the mouth is the oropharynx. The lower part of the passage at the opening of the esophagus is hypopharynx. The part above the trachea and esophagus is the aditus of the larynx. The posterior border of the passage is the buccopharyngeal fascia. Behind this is the vertical space the retropharyngeal space. And posterior to that is the prevertebral fascia.
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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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