Awake Fibreoptic

Intubation
Kashmira Purbhoo

Indication
Any situation in which a GA may compromise the
safety of a patient with a difficult / potentially
difficult intubation and/or facemask ventilation
Contraindications:
Patient refusal
Inexperience
LA hypersensitivity
Non-compliant / uncooperative patient e.g. children
Significant airway bleeding
Critical airway (patient with severe stridor e.g. acute
epiglottitis)

Informed Consent
The procedure must be explained to the
patient and consent obtained
If conscious sedation is to be used the
patient must understand that some degree
of recall is possible

Preparation of equipment and

drugs
All the equipment must be ready for use
e.g. suction attached, ETT railroaded over
scope, light source checked etc.
All the drugs needed for the intubation
sedation & GA must be drawn up
Emergency drugs must be readily available

Monitoring and IV access

Standard monitoring as for any GA
Good, secure IV access

Anti-sialogogue
Glycopyrolate 4 g/kg iv when patient
arrives in theatre (can also be given s/c or
imi 60 min before intubation also 4
g/kg)
OR

Atropine 10 g/kg ivi

Patient positioning
Usually supine with anaesthetist behind
the patient at the head of the table
If patient cannot tolerate supine position:
semi-Fowlers (sitting) position with
anaesthetist in front of patient (image will
be inverted on screen)

Supplemental Oxygen
Should always be used
facemask still allows access if performing nasal
intubation
small size oral RAE ETT placed in adjacent nostril

Conscious Sedation
Contraindicated if it may compromise
patient safety
Patient must be able to follow verbal
commands
Many techniques are available
Dexmeditomidine or propofol &
remifentanil preferred by most

Topical vasoconstriction
Applied nasally
Decreases localized blood flow
Prolongs effect of local anaesthetic

Local anaesthesia of the airway

Calculate toxic dose of lignocaine (up to 9mg/kg if
only applied topically)
Nose and nasopharynx
Nasal mucosa, uvula, superior aspect of tonsils and
nasopharynx are innervated by the trigeminal nerve
(sphenopalatine ganglion)
Gently pack nose with ribbon gauze soaked in 2% lignocaine

Oropharynx
The oropharynx & the posterior third of the tongue are
innervated by the glossopharyngeal nerve
atomized lignocaine 4% 4-6 ml (use 2% if 4% not available) or
gargle with lignocaine

Local anaesthesia of the airway

Larynx
Spray-as-you-go 2% lignocaine via epidural
catheter inserted through side port
2ml sprayed onto cords when visualized (superior laryngeal nerve
innervates arytenoids, epiglottis and mucosa above the cords)
2ml sprayed onto tracheal mucosa (recurrent laryngeal nerve
innervates mucosa below the cords) or

Translaryngeal block
20G cannula advanced through cricothyroid membrane until air
aspirated
Remove needle and leave cannula
Patient asked to exhale fully
Inject 3 ml 2% lignocaine inspiration & coughing will allow LA to
spread

Bronchoscopy and intubation

There are 3 possible movements:
Tip up/down
Scope inserted deeper or withdrawn
Rotation of scope (scope must be kept straight)

Always move target to center of screen before advancing

If the scope is sitting in secretions or touching mucosa, withdraw
slightly until view has been re-established
Forward advancement of jaw (or jaw thrust) significantly
improves visualization when the scope enters the pharynx
Lubricate outside of the ETT tube before advancing through the
nostril/mouth
A drop of saline inside the tube may reduce friction on the scope
If the ETT gets caught on the arytenoids, gently twist the ETT
while advancing (a beveled ETT e.g. the reinforced ETT used with
the intubating LMA often advanced with less resistance)

General anaesthesia and ventilation

Inflate the ETT cuff only once the patient is
under GA

Post Procedure
At the end of surgery , before extubation, ensure that
The patient has been oxygenated with high FiO2 for 3-5
mins
Any muscle relaxants have been adequately reversed
The upper airway is free of all secretions the airway may
still be anaesthetised and laryngeal reflexes are not intact.
Pulmonary aspiration a risk
The patient is breathing spontaneously with adequate tidal
volumes
The patient is awake
Have all possible equipment for possible re-intubation at
hand

Cleaning of equipment
Follow proper cleaning protocols to ensure
longevity of equipment
Scope must ready to be used

Thank You