Awake fiberoptic intubation
Clinical Procedure
 
Aliases:
Nasal awake fiberoptic intubation
Oral awake fiberoptic intubation
AFOI, AFI, AI

Topic aliases are alternate phrasings for a particular topic.


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Maxillofacial fractures are a relatively strong contraindication to nasal fiberoptic intubation. There is a risk of creating a false lumen at the site of the fracture. Consider proceeding only if is determined to be low risk following discussion with the surgeon and examining imaging. #ref

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Oct 04, 2011
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What to say if the patient with an expected difficult airway refuses awake intubation. refl.in/55 From Benumof's Airway Management.

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Mar 12, 2012
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Silicon endotracheal tubes with hemispherical bevel (bullet nosed, bullet tipped) from intubating LMA kits are easier to insert and result in less nasal trauma than PVC endotracheal tubes. Image from paper - refl.in/f3 Due to the difficulty in suctioning past the tip, and the low tracheal cuff volume, these are not suitable for patients requiring postoperative ventilation. www.ncbi.nlm.nih.gov/pubm...

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Apr 07, 2012
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For administering topical LA to cords, place epidural catheter down suction port with tip sticking out end by 5mm. Attach 5ml syringe with connector with 2ml solution + 3ml air. Inject onto cords
#pic

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Nov 28, 2012
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If pathology is expected, having an external view of the image so that other staff (eg surgeons) can see it will be useful when deciding on the extubation strategy.

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Mar 16, 2012
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Oral route: If having difficulty with the sharp angle required to get around tongue, a berman airway or ovassapian airway may help guide the scope.

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Nov 28, 2012
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Standard monitoring including non-invasive blood pressure, pulse oximeter, ECG, and intravenous access, prior to proceeding

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Oct 07, 2011
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Pre-medicate with an antisialogogue such as glycopyrrulate 10-15min prior to procedure to dry airway secretions. This will also aid topical anaesthesia.

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Nov 28, 2012
Glycopyrrulate 200-400mcg IV in adult
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If the patient is in pain from swelling or infection, coughing as the vocal chords are sprayed and insertion of the tracheal tube will exacerbate this. Consider providing analgesia such as titrated fentanil or remifentanil to cover this.

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Nov 28, 2012
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Oral fibreoptic intubation is usually better tolerated than nasal, as long as the posterior oropharynx is well topicalised to reduce the patient's gag response.

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Nov 28, 2012
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If using Berman airway to guide scope around tongue, use it first to apply topical anaesthesic gel to posterior tongue

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Mar 12, 2012
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Oral route: Have patient gargle 4ml viscous lignocaine 2% to topicalise oropharynx.

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Aug 05, 2011
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This study suggests that benzonatate capsules provide rapid and reliable oropharyngeal anesthesia in preparation for awake intubation. refl.in/54

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Note that in this study these patients were also administered 4 ml of 4% lidocaine translaryngeally (transtracheal puncture).
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For the nasal approach, topicalise the nasal passages with 3-4 sprays of cophenylcaine prior to insertion to provide analgesia and vasocontriction to reduce bleeding. Each spray (~100microL) delivers approximately 5mg of lignocaine and 0.5mg phenylephrine. #ref

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Mar 12, 2012
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Options for nerve blocks. Superior laryngeal, glossopharyngeal, and recurrent laryngeal nerve. refl.in/60

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May 24, 2011
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Video of a fairly smooth, awake oral fibreoptic self intubation with a transtracheal puncture and topicalisation.

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May 14, 2012
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