Awake Fiberoptic Intubation (anticipated difficult airway)
Patient phenotype
Anticipated difficult airway: anatomy (small mouth, large tongue, limited neck mobility, micrognathia), pathology (oral/laryngeal tumor, RA cervical spine, prior radiation, trauma), or unstable C-spine.
Procedure
Topicalize airway with local anesthetic, advance flexible fiberoptic scope through nose or mouth into trachea, railroad ETT over scope. Patient awake + spontaneously breathing throughout. ~10-30 min.
Anesthetic plan
Light sedation (dexmedetomidine ideal — preserves spontaneous ventilation), aggressive topicalization (lidocaine 4% nebulized + atomized + nerve blocks if needed), antisialagogue 30 min before. Patient cooperative, comfortable, breathing room air.
Setup
- ·Standard ASA monitors
- ·PIV
- ·Glycopyrrolate 0.2 mg IV 30 min pre-op (dries secretions for visibility)
- ·Lidocaine: 4% nebulized + 4% atomized + 2% jelly + 10% spray + lubrication for ETT
- ·Flexible fiberoptic bronchoscope + appropriate ETT (6.0 typical adult)
- ·Dexmedetomidine 0.5-1 mcg/kg load + 0.5-1 mcg/kg/hr
- ·Backup: video laryngoscope + emergency cric kit (if awake fails)
- ·Suction at bedside
Biggest concerns by phase
Patient explanation + cooperation
Fully explain procedure to patient — tell them they'll feel pressure, may cough, won't be able to talk briefly when scope passes cords. Cooperation is everything. Topicalization makes it tolerable. Consider antianxiety + analgesia.
Antisialagogue + topicalization sequence
Glyco 0.2 mg IV 30 min before procedure → dries secretions for fiberoptic view. Topicalization: 4% lidocaine nebulizer 10 min OR 4 mL atomized via MAD device. Spray base of tongue + soft palate with 10% lidocaine 1-2 sprays. Gargle 4% lido + spit. Don't exceed 5 mg/kg total.
Sedation — maintain spontaneous ventilation
Dexmedetomidine 0.5-1 mcg/kg load over 10 min then 0.5 mcg/kg/hr — sedation without respiratory depression. Avoid propofol bolus (apnea = lost airway). Avoid opioid bolus (apnea). Fentanyl 25-50 mcg titrated very slowly OK for analgesia.
Fiberoptic technique — cooperate with patient breaths
Pass scope through nose (better tolerated) or mouth (faster). Visualize: nasopharynx → uvula → epiglottis → glottis (may need patient to breathe deep + extend neck). Through cords during inspiration. Confirm in trachea by seeing carina. Railroad ETT over scope. Confirm tube position with bronch + ETCO₂.
Complications: total airway obstruction, LAST, vasovagal
Total airway obstruction (loss of 'awake' insurance) = emergency. LAST from local OD: stop, lipid emulsion. Vasovagal from gag/topicalization: atropine ready. Bleeding from nasal passage (use phenylephrine spray + pretreat).
After successful intubation
Once tube confirmed in trachea, secured, give standard induction agents (propofol, NMB) for surgical anesthesia. Document the technique used (helps future anesthetists).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your patient has a large supraglottic tumor — Mallampati IV, can open mouth 2 cm, mass visible on neck. You decide on awake fiberoptic. Walk me through your plan from preop to intubation.
What an examiner probes for
- ▹Glyco 0.2 mg IV 30 min pre-op
- ▹Topicalization: 4% nebulized + atomized to base of tongue + glottis
- ▹Sedation: dex load + infusion (NOT propofol bolus)
- ▹Maintain spontaneous ventilation throughout
- ▹Backup plans: surgical cric, awake trach (even more conservative)
- ▹Documentation for future records
Sources
- DAS Awake Fiberoptic Guidelines
- Miller's Ch 66
- ASA Practice Advisory: Difficult Airway 2022
Anatomy reference
Sourced reference images. 4 matches for "larynx airway trachea".
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