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Expanded Guide:
Awake Fiberoptic Intubations

The thing about performing an awake fiberoptic intubation is that sometimes they just don't go as smoothly as we'd like. There's also a perception that they eat up valuable OR time. And while we should be frank with patients that being intubated fiberoptically while awake won't be "fun", the choice to omit an awake fiberoptic when warranted has high potential to be life threatening, will definitely eat up OR time, and is most certainly not "fun".

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This how-to aims to help streamline your approach to awake fiberoptic intubations, making the entire process more efficient and more comfortable for the patient - and also for you.

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Let's get started.

PART 1: CONSENT

An informed patient will be their own best advocate.

Say something like,

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“Hey Mrs. Woody Neck, the stiffness and scarring around your neck and windpipe has us all a bit worried. Before we proceed with your surgery today, we need to place a breathing tube in your windpipe while you're still awake and able to breath on your own, as we simply cannot guarantee that we would be able to safely "breathe for you" if we were to put you to sleep without first placing that breathing tube. We’re going to take away your gag and cough reflexes for a few minutes to do this. That will entail applying numbing medicine to your mouth and throat. We’re going to keep you as comfortable as we can and we will carefully add some light sedation to your IV as well, but not so much that you could get sleepy and stop taking deep breaths on your own. Everything we are planning is because we absolutely do not want to take any gambles here, not where your life and safety are concerned.”

Part 2: Dry the Airway

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Give glycopyrrolate. ASAP.

Preferably this would be administered immediately after consent. This will allow for adequate drying time well BEFORE topicalization attempts.

Part 3: Basic OR Setup

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Streamline your setup. Streamline your efficiency.

Along with your typical room setup (MOM SAID or whatever you use) - Prepare and position all of your equipment prior to beginning any topicalization. Keep in mind that topical lidocaine densest numbing effects do not last nearly as long as you wish they did (10-20 minutes). Serum levels will far outlast the numbing effects. Plan ahead to prevent any delays and avoid having to redose.

Part 4: Basic Setup for Lidocaine Delivery

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This is a suggested setup. Got a better method? Use it.

Get these lidocaine delivery devices set up while glycopyrrolate does its thing.

Part 5: Topical Lidocaine Dosing Basics

Lidocaine toxicity? In a difficult airway? No thank you.

There is no consensus on maximum lidocaine dosage when applied topically to the airway mucosa. The FDA recommendations (4.5 mg/kg LBW w/o epi; up to a 300 mg maximum dose) are for injection maxes and are not site specific. Adding to the complexity surrounding best practice with lidocaine dosing, it is also important to note that toxicity has been demonstrated even with doses well below maximum recommendations. Thus always take care to note those at heightened risk for local anesthetic toxicity and always use the smallest dose necessary and decrease accordingly.

Part 6: Nerve Targeted Topicalization

Numerous options. We've tried to narrow our focus to an approach that is effective but also easy to perform. If you already have a method that works, then by all means keep using it.

Sequential topicalization in a time efficient manner. We often begin glossopharyngeal topicalization in the preop holding bay (always with standard monitors, suction and oxygen availability) and then complete the remainder of topicalization in the OR. Tailor you approach on what makes the most clinical sense.

Part 7: Intubate

Patient informed. Monitors on. Mucosa numbed. Its go time.

Here are the basic steps for the intubation along with a couple of scope driver's ed basics. 

If you ever need a refresher

Coming soon.... 

Conclusion

The awake fiberoptic intubation remains the gold standard for difficult airway management. It is therefore of vital importance that providers feel empowered to successfully perform this procedure in a variety of clinical settings, and to do so in a way that is both safe and expedient. We will continue to face mounting production pressure going forward, but patient safety need not be compromised. To this end, a streamlined technique, such as this, can be both fast and safe.

Keep in Mind

Your patient will be taking their cues both from you and the others in the room. That being said, try to project a sense of calm confidence. Remind any trainees assisting you to do the same.

Dive deeper.

National and international awake airway management resources to compliment your practice

NAP4 Project

1

The NAP4 Project identified numerous cases where an awake fiberoptic intubation was indicated but was not used. There were cases suggesting lack of skills, lack of confidence, poor judgement and in some cases lack of suitable equipment being immediately available. This latter problem was especially prevalent on ICU. Awake intubation should be used whenever it is indicated. This requires that anesthetic departments and individual anesthesiologists ensure such a service is readily available.

2022 ASA Difficult Airway Alhorithm

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The American Society of Anesthesiologists’ (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to guide the anesthesiologist’s choice of pathway in the ASA’s Difficult Airway Algorithm. Entry into the awake intubation pathway is encouraged when the patient is judged at risk of difficult tracheal intubation and one or more of the following: difficult ventilation, significant aspiration risk, and/or rapid oxyhemoglobin desaturation.

2019 DAS ATI Guidelines

3

The 2019 Difficult Airway Society guidelines can offer a complimentary perspective for the approach to the awake tracheal intubation (ATI) in adults. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.

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