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Chapter 53. Awake Fiber-Optic Intubation

Arthur Atchabahian, MD

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Advantages of nasal intubationDisadvantages of nasal intubation
  • Easier, as the path is straighter from nasopharynx to glottis
  • Less gagging as minimal contact with tongue base
  • Patient cannot bite tube/bronchoscope
  • Potential for epistaxis (avoid, e.g., in pregnant patients)
  • Risk of sinusitis if kept in place for >48 h

  • Patient must be given a complete explanation of the entire procedure, to enhance cooperation, and to allay anxiety
  • Adequate IV access
  • Check equipment; all medications, including emergency medications, immediately available
  • Backup airway access devices (LMAs, cricothyrotomy kits) should be immediately available
  • Obtain knowledgeable help if available
  • Surgeon informed, available for surgical airway if needed:
    • In some especially difficult cases, the neck might be prepped, and the surgeon gowned, ready to secure a surgical airway if needed

  • Adequate sedation is important to minimize anxiety and hemodynamic swings
  • However, avoid excessive sedation leading to airway obstruction and hypoventilation, which could be catastrophic in patients with difficult/impossible mask/airway
  • Use small amounts of midazolam (1–2 mg) to provide amnesia
  • A dexmedetomidine infusion, starting at 4 μg/kg/h, until eye closure and visible relaxation, and then decreased to 1.5–2 μg/kg/h, provides adequate sedation with little or no respiratory depression or obstruction:
    • Monitor for bradycardia; reduce infusion rate if needed

  • 100% O2 by non-rebreather mask for at least 5 minutes
  • Unless rate-dependent angina, antisialagogue (glycopyrrolate 0.2–0.4 mg IV), and, if indicated, metoclopramide (10 mg IV)
  • Airway blocks (see Chapter 52) can be used depending on personal preferences:
    • Transtracheal block useful as other techniques do not topicalize trachea (below the cords)
    • Glossopharyngeal and superior laryngeal blocks less widely used currently; adequate topicalization and dexmedetomidine is usually sufficient
  • For anticipated oral approach:
    • Patient is asked to swish, gargle, and spit out 3–4 mL lidocaine 4% several times, or
    • The oropharynx is sprayed with topical benzocaine/tetracaine preparations (e.g., Hurricaine; do not exceed 3 seconds of spraying: risk of methemoglobinemia with benzocaine)
    • 6 mL lidocaine 4% is nebulized using a handheld nebulizer
  • For anticipated nasal approach:
    • Patient self-administers three puffs of a nasal vasoconstrictor (oxymetazoline 0.05% [Afrin®]) into each nostril
    • 5 mL of viscous lidocaine 2% is administered into each nostril; patient is asked to retain volume in nostrils as long as possible, and then asked to inhale and swallow the volume; this procedure is repeated for a second dose
    • 6 mL lidocaine 4% is nebulized using a handheld nebulizer

  • Patient positioned to maximize access to mouth, and to align the oral, pharyngeal, and laryngeal axes, thus placing the patient in a “sniffing” position:
    • Typically, the patient is positioned supine or semirecumbent, with the operator standing behind the head
    • Occasionally, for example, in the morbidly obese or for patients with neck masses, having the patient sitting up, with the operator standing in front of the patient, can facilitate the procedure and reduce airway obstruction
  • Generously lubricate appropriately sized endotracheal tube (ETT), and position tube into a ...

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