AWAKE INTUBATION FIBRE OPTIC INTUBATION, REVISION 1 PAGE TABLE FORMAT, MEMORY DEVICES FOR EXAM
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Awake Fibreoptic Intubation (AFOI) — Revision Table (1-Page)
Source: Cummings Otolaryngology Head & Neck Surgery (Ch. 6, "Awake Fiberoptic Intubation," Box 6.1, Box 6.2); supplemented by Bailey & Love's Short Practice of Surgery.
| Domain | Key Points |
|---|---|
| Definition | Securing the airway with an endotracheal tube (ETT) railroaded over a flexible fibreoptic bronchoscope in a spontaneously breathing, conscious (± sedated) patient — preserves airway tone and spontaneous ventilation throughout. |
| Historical note | First used for nasotracheal intubation in Still's disease (1967, choledochoscope); first fibreoptic bronchoscope intubation in severe rheumatoid arthritis (1972); Stiles et al. reported first series of 100 cases. |
| Indications (Box 6.1) | I. Difficult intubation – known/anticipated OR unanticipated failed intubation. II. Compromised airway – upper airway pathology (mass/oedema/trismus) or lower airway (tracheal compression). III. Awake intubation preferred – high aspiration risk, neck movement undesirable (unstable C-spine), known difficult mask ventilation, morbid obesity, need for self-positioning. IV. High risk of dental damage. |
| Contraindications | Fixed stenotic lesion that won't allow ETT passage without dilation; significant bleeding obscuring the view; patient unable to cooperate. |
| Equipment | Fully stocked videobronchoscopy cart (nasopharyngeal airways, standard + long micro-laryngoscopy tubes, resuscitation/monitoring equipment). Cart positioned at patient's left/head of bed; operator stands on patient's right and faces patient + video monitor. |
| Patient preparation – Psychological | Reassuring pre-op visit explaining rationale (patient safety); enlist active cooperation (head position, deep breathing, clearing secretions). |
| Patient preparation – Pharmacological | 1) Antisialogogue (e.g., glycopyrrolate) unless contraindicated — dries secretions for better view. 2) Sedation: none for severely compromised airway; conscious sedation (fentanyl + midazolam, or remifentanil infusion) for most — goal is calm, cooperative, spontaneously breathing patient, NOT unresponsive. 3) Standard monitors + high-flow nasal cannula O₂ throughout. |
| Topical/local anaesthesia | Oropharynx: benzocaine 20% spray, gargle/swallow; nebulised 2% lidocaine 5 mL. Vocal cords: transcricothyroid injection of 2% lidocaine 2 mL (patient coughs to spread it) ± superior laryngeal nerve block. Nose (if transnasal): vasoconstrictor (oxymetazoline 0.05%/phenylephrine 1%) then 4% lidocaine spray or pledgets, given 5 min before instrumentation. Balance is key — over-anaesthetising impairs secretion handling. |
| Technique (transnasal, preferred by otolaryngologists) | 1. Head of bed elevated, patient sitting upright if possible. 2. ETT warmed in saline (softens it), cuff deflated. 3. Nasal passage progressively dilated with lubricated nasal trumpets. 4. ETT inserted, directed inferiorly; if it fails to turn toward oropharynx, withdraw and rotate 90°. 5. Bronchoscope passed through ETT, glottis visualised; jaw thrust/tongue traction if view difficult. 6. Top-up 1–2 mL 4% lidocaine via scope side channel at cords if patient guards. 7. Advance scope through cords into trachea, then railroad ETT over scope. 8. Confirm position (carina view) and remove scope. |
| Complications | Epistaxis/trauma from nasal instrumentation, laryngospasm, airway oedema, oesophageal misplacement, desaturation/hypoxia if procedure prolonged, haemodynamic surge (HTN/tachycardia) from inadequate topicalisation or patient distress, failure requiring conversion to surgical airway. |
| Keys to success (Box 6.2) | I. Expert endoscopist. II. Functioning bronchoscope + supplies. III. Patient preparation: (A) psychological, (B) pharmacological — premedication (light/no sedation if calm, heavier if anxious, antisialogogue), IV sedation (none if severely compromised, conscious sedation for most, heavy only if uncooperative), topical anaesthesia route-specific (oral vs nasal) + monitoring/O₂. |
Memory Devices for Exam
1. Indications — "DAMP"
- D – Difficult airway (known or unanticipated failed intubation)
- A – Aspiration risk high
- M – Mask ventilation difficult / Morbid obesity / neck Movement restricted (C-spine)
- P – Positioning (self-positioning needed) / dental damage risk Precludes laryngoscopy
2. Contraindications — "SUB" (things that "sink" the plan)
- S – Stenosis (fixed, won't dilate)
- U – Uncooperative patient
- B – Bleeding obscuring the view
3. Pillars of Preparation — "PAST"
- P – Psychological (reassurance, informed consent, cooperation)
- A – Antisialogogue (glycopyrrolate)
- S – Sedation (titrated - calm but responsive, never obtunded)
- T – Topicalisation (nose → oropharynx → cords, route-specific)
4. Topicalisation Order (nose to cords) — "SLIC" (top to bottom)
- S – Shrink/vasoconstrict nose (oxymetazoline/phenylephrine)
- L – Lidocaine gel on nasal trumpets (dilate passage)
- I – Inhaled/sprayed lidocaine to oropharynx (nebulised 2%, benzocaine spray)
- C – Cricothyroid injection of lidocaine for the cords (± superior laryngeal nerve block)
5. Golden Rule of Sedation — "Awake, not asleep"
A mildly uncomfortable but responsive, spontaneously ventilating patient beats a deeply sedated, apnoeic one. If they stop protecting their airway, you've lost the entire point of doing it "awake."
6. Keys to Success — "EPT"
- E – Expert endoscopist
- P – Proper (functioning) equipment
- T – Total patient preparation (psych + pharm + topical)
7. Complications — "BLEEDS"
- B – Bleeding/trauma (nasal/laryngeal)
- L – Laryngospasm
- E – Edema (airway swelling from repeated attempts)
- E – Esophageal misplacement
- D – Desaturation/hypoxia
- S – Sympathetic surge (HTN/tachycardia from inadequate topicalisation)
(Mnemonics above are original memory aids built from the source content, not verbatim textbook mnemonics — useful for recall but verify indication/contraindication lists against Box 6.1 wording for exact exam phrasing.)
Recent evidence note (2025 systematic reviews — may refine guideline-level detail beyond this textbook chapter)
- Guideline recommendations on assessment and management of awake airway intubation - systematic review of guidelines (PMID: 39966725)
- Sedation for awake tracheal intubation: network meta-analysis in Anaesthesia comparing sedation regimens (PMID: 39468765)
- Systematic review/meta-analysis on awake vs asleep intubation specifically for mediastinal goiters (PMID: 40444686) - relevant if your exam covers special populations
These don't contradict the textbook table above but reflect newer guideline consolidation and sedation-choice evidence you may want to skim if your exam emphasizes "latest guidelines."
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