3. History
Peter Murphy, in England, in 1965 used a fiberoptic
choledocosope to intubate nasally a pt with Still’s disease.
4. Indications for Awake Intubation
Need for intubation where ability to ventilate via mask or
supraglottic airway is unlikely or poses an aspiration risk
History of need for awake intubation
Anatomic features that are worrisome
Limited mouth opening, reduced neck mobility, cervical spine
instability, anatomic malformations of mandible or larynx,
congenital deformities (Pierre Robin), head and neck cancers,
trauma to the face, airway.
5. How common are difficult
airways
Review of 50,000 records excluded planned fiberoptics
Found impossible to mask was only 0.15%, and 25% of
those were difficult to intubate
6. Neck movement
When compared with DL or glidescope FOI causes less
movement of cervical spine
7. Techniques: Nasal
Preferred when:
large tongue, limited mouth opening
receding lower jaw, or tracheal deviation
or in cases in which an unobstructed surgical field is
beneficial (eg, dental surgery).
This approach is also anatomically favorable in that the
laryngeal opening is more easily seen with the fiberscope as
it courses past the nasopharynx with less obstruction by the
tongue
8. Nasal
Anti-sialogogue: Glycopyrollate 0.1-0.2mg
Afrin or phenylephrine and lidocaine to nare, ask which is more
open
Inhaled nebulized lidocaine at 5l/min flow for correct droplet
size, not trying to get into lungs, have pt stick out tongue
Spray additional high concentration lidocaine through atomizer
into back of throat and directed down on cords
5% lidocaine ointment onto tongue depressors with 4x4
attached, paint back of throat and let drip down while pt bites on
tongue blade
Plus/minus trans-tracheal injection of lidocaine, more
concentrated is better
Can also “spray as you go”
9. Nasal continued
Dilate nare with increasing size of lubed NP airways
Insert tube with gentle pressure until passes into oropharynx,
then inflate balloon and draw back until resistance is felt
Insert fiber and pass into cords, deflate cuff and advance tube
Ideally use smaller tube, 6-5 or 7-0 better than 7-5 or 8-0 due to
ease of passage into trachea
If you cannot visualize cords, try having someone do a jaw
thrust and/or pull the tongue out of the mouth with a 4x4
If scope is in trachea but tube won’t pass, withdraw slightly and
rotate 90 degrees and try again, then another 90 degrees. If
necessary try corkscrew
Parker Flex tip tube has curved tapered distal tip to slide past cords
more easily
10. Oral
Harder due to tongue, more anterior path needed to get to
cords
No nasal prep needed, otherwise the same
Can use special oral airway such as Ovassapian with central
channel to pass scope
Jaw thrusts and tongue out can really help here
Key is staying midline, walk along the tongue, manipulate
ETT
11. Nerve Blocks
Glossopharyngeal nerve supplies sensory to posterior third of
tongue, vallecular, anterior epiglottis, walls of pharynx, tonsils
Block by holding pledgets with lidocaine at tonsillar pillars or
injecting at mandible and mastoid processes.
Superior laryngeal nerve provides sensory to base of tongue
and posterior surface of epiglottis to arytenoids.
Block by injecting local at cornua of hyoid bone
Vagus nerve branches (recurrent laryngeal) supply sensory
innervation to the underside of epiglottis and trachea
Transtracheal block
1% lido can last 75 minutes, up to 400 minutes with 1:200,000
epi
12. Sedation
Depends on how scary the airway is, okay to use no sedation
Versed +/- fentanyl
Remi bolus vs drip (0.5-1mcg/kg and 0.05-0.1 mcg/kg/min)
Ketamine bolus vs drip (0.3-0.5mg/kg and 10mcg/kg/min)
Precedex, load and drip (0.4-1mcg/kg bolus over 10 min + 0.5-
1mcg/kg/HR)
General anesthesia with spontaneous ventilation, inhaled or propofol
More hypoxia with propofol
Remi vs. Prop: Remi better conditions, better tolerated, patients
breathed when told to
Precedex vs prop: Precedex superior in terms of hemodynamic stability
and not having airway obstruction
Precedex vs remi: Precedex better in terms of desaturations
Johnston KD and Rai MR Consious Sedation for awake fiberoptic intubation:
a review of the literature. Can J Anesth (2013) 60:584-599.
13. Other techniques
Fiber through LMA
Awake glidescope
Awake DL
DL and fiber or glidescope and fiber