Awake fiberoptic intubation - Revision history

Spate215 at 22:19, 17 March 2026

2026-03-17T22:19:03Z

← Older revision		Revision as of 15:19, 17 March 2026
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	'''<big><u>Introduction</u></big>'''		'''<big><u>Introduction</u></big>'''
	* Fiberoptic intubation remains the gold standard for securing the airway in patients with a known or anticipated difficult airway. When performed by experienced clinicians, this technique can be accomplished with efficiency comparable to that of video laryngoscopy.		* Fiberoptic intubation remains the gold standard for securing the airway in patients with a known or anticipated difficult airway. When performed by experienced clinicians, this technique can be accomplished with efficiency comparable to that of video laryngoscopy<sup>1</sup>.
	*Bronchoscopes may be rigid or flexible; however, the flexible fiberoptic bronchoscope is preferred for awake intubations, as it allows for both oral and nasal approaches. This review will focus specifically on the oral awake fiberoptic technique.		*Bronchoscopes may be rigid or flexible; however, the flexible fiberoptic bronchoscope is preferred for awake intubations, as it allows for both oral and nasal approaches. This review will focus specifically on the oral awake fiberoptic technique.
	*Modern fiberoptic bronchoscopes are typically connected to a video monitor, enabling real-time visualization of airway anatomy by the entire care team. In addition to visualization, the instrument’s working channel permits suctioning of secretions, supplemental oxygen delivery, and administration of topical anesthetics or other medications.		*Modern fiberoptic bronchoscopes are typically connected to a video monitor, enabling real-time visualization of airway anatomy by the entire care team. In addition to visualization, the instrument’s working channel permits suctioning of secretions, supplemental oxygen delivery, and administration of topical anesthetics or other medications.
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	** Scopes of varying sizes and calibers		** Scopes of varying sizes and calibers
	** ETTs of varying sizes		** ETTs of varying sizes


			'''<u>References</u>'''

			# Rosenstock CV, Thøgersen B, Afshari A, et al. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management: a randomized clinical trial. Anesthesiology. 2012;116(6):1210-6.

Spate215 at 20:39, 17 January 2026

2026-01-17T20:39:33Z

← Older revision		Revision as of 13:39, 17 January 2026
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	'''<big><u>Introduction</u></big>'''		'''<big><u>Introduction</u></big>'''
	* ~~This is~~ the ~~mainstay~~ for securing the airway ~~for~~ a ~~patient who is~~ known ~~to be a true~~ difficult airway		* Fiberoptic intubation remains the gold standard for securing the airway in patients with a known or anticipated difficult airway. When performed by experienced clinicians, this technique can be accomplished with efficiency comparable to that of video laryngoscopy.
	* Studies have shown that providers who are skilled with the fiberoptic scope can ~~intubate as quickly as one would~~ with a video ~~laryngoscope~~		*Bronchoscopes may be rigid or flexible; however, the flexible fiberoptic bronchoscope is preferred for awake intubations, as it allows for both oral and nasal approaches. This review will focus specifically on the oral awake fiberoptic technique.
	* Bronchoscopes		*Modern fiberoptic bronchoscopes are typically connected to a video monitor, enabling real-time visualization of airway anatomy by the entire care team. In addition to visualization, the instrument’s working channel permits suctioning of secretions, supplemental oxygen delivery, and administration of topical anesthetics or other medications.
	** Can be ~~either~~ rigid or flexible, ~~however~~ flexible is ~~more appropriate~~ for awake ~~fiberoptics~~ as it ~~can allow~~ for both an oral or nasal ~~approach~~. We will focus on oral awake fiberoptic ~~intubations in this article~~
	** Will be attached to ~~screen to allow other parties to see the~~ airway anatomy
	** Can be used to ~~suction~~, ~~oxygenate~~, or ~~administer~~ medications ~~as it has a working channel~~


	'''<big><u>Indications</u></big>'''		'''<big><u>Indications</u></big>'''

	* ~~Previously noted to be~~ difficult ~~intubation~~		* History of prior difficult airway management, particularly in patients with documented multiple failed intubation attempts.
	* Hx of multiple failed intubation attempts		*Clinical examination findings that suggest a potentially challenging airway—such as those associated with facial or airway trauma, infection, or anatomic distortion
	* Clinical ~~exams~~ that ~~is suggestive of difficult~~ airway ~~(i.e.~~ trauma, infection)		*Cervical spine pathology or those in whom neck manipulation must be minimized
	* Cervical ~~Spine disease~~ or ~~inability to manipulate the~~ neck


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	** Supplies innervation to the oropharynx, vallecula, and base of tongue		** Supplies innervation to the oropharynx, vallecula, and base of tongue
	* Vagus Nerve		* Vagus Nerve
	** Provides innervation the posterior pharynx, vocal cords, and trachea via two ~~major~~ nerve branches (Superior Laryngeal Nerve + Recurrent Laryngeal Nerve)		** Provides innervation the posterior pharynx, vocal cords, and trachea via two principle nerve branches (Superior Laryngeal Nerve + Recurrent Laryngeal Nerve)
	*** Superior Laryngeal Nerve		*** Superior Laryngeal Nerve
	**** Sensory: Above the vocal cords		**** Sensory: Above the vocal cords
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	* '''Sedation'''		* '''Sedation'''
	** The entire point of this procedure to keep the patient awake and to maintain spontaneous ventilation. Therefore, it is critical that we do not over sedate the patient and potentially cause apnea of collapse of airway structures		** The entire point of this procedure to keep the patient awake and to maintain spontaneous ventilation. Therefore, it is critical that we do not over sedate the patient and potentially cause apnea or collapse of airway structures
	** However, with the being said, this is an incredibly uncomfortable and anxiety producing procedure for patients		** However, with the being said, this is an incredibly uncomfortable and anxiety producing procedure for patients and therefore warrants some level of sedation, if able
	** Commonly used medications:		** Commonly used medications:
	*** Midazolam		*** Midazolam
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	**** If using Ketamine, consider administering Glycopyrrolate (0.2 mg IV) to help minimize the production of secretions. It must be given atleast 20 minutes prior to intubation to see effects.		**** If using Ketamine, consider administering Glycopyrrolate (0.2 mg IV) to help minimize the production of secretions. It must be given atleast 20 minutes prior to intubation to see effects.
	**** It can also cause patients to clench their jaw or become dissociated with the inability to follow commands		**** It can also cause patients to clench their jaw or become dissociated with the inability to follow commands
	*** Propofol ~~(low dose)~~		*** Propofol
	** Of note, systematic reviews and meta ~~analysese~~ have shown that there is no significant difference in the success rate between all of the different ~~medication~~ options.		** Of note, systematic reviews and meta analyses have shown that there is no significant difference in the success rate between all of the different sedation options.
	*** The only difference that was noted was that there were lower frequency of desaturations when Precedex was used.		*** The only difference that was noted was that there were lower frequency of desaturations when Precedex was used.
	* '''Localizing'''		* '''Localizing'''
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	**** Target the tonsils, uvula, and vocal cords		**** Target the tonsils, uvula, and vocal cords
	*** Nebulizer		*** Nebulizer
	**** Attached to a green face mask that has Lidocaine 4% in ~~it.~~		**** Attached to a green face mask that has Lidocaine 4% in the chamber
	**** This will take the longest time, but can be useful for the patient to inhale if you have > 15 minutes for the nebulization to be fully effective		**** This will take the longest time, but can be useful for the patient to inhale if you have > 15 minutes for the nebulization to be fully effective
	*** Lollipops		*** Lollipops
	**** Place gauze around a tongue depressor and cover it in Lidocaine jelly/ointment. Have the patient place this ~~as deep~~ in their mouth as tolerated and allow them to suck on it. Every few minutes, advance the tongue depressor further as the prior portion of the pharynx should have become numb.		**** Place gauze around a tongue depressor and cover it in Lidocaine jelly/ointment. Have the patient place this in their mouth as deep as tolerated and allow them to suck on it. Every few minutes, advance the tongue depressor further as the prior portion of the pharynx should have become numb.
	**** The lidocaine will melt and release droplets that will spread		**** The lidocaine will melt and release droplets that will spread
	*** Injection of lidocaine via fiberoptic scope		*** Injection of lidocaine via fiberoptic scope
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	**** Inject on either side of the greater cornu of the hyoid bone		**** Inject on either side of the greater cornu of the hyoid bone
	*** Recurrent Laryngeal Nerve		*** Recurrent Laryngeal Nerve
	**** Can be done via a transtracheal block. Needle is inserted through the cricothyroid membrane while aspirating ~~uncle~~ air returns. Once you have air, inject local. The patient will cough, which will help spread local anesthetic upwards.		**** Can be done via a transtracheal block. Needle is inserted through the cricothyroid membrane while aspirating until air returns. Once you have air, inject local. The patient will cough, which will help spread local anesthetic upwards.
	**** Encourage the patient to suppress cough until the needle has been removed (I know, easier said than done)		**** Encourage the patient to suppress cough until the needle has been removed (I know, easier said than done)
	* '''Positioning'''		* '''Positioning'''

Spate215 at 20:33, 17 January 2026

2026-01-17T20:33:03Z

@@ Line 1: / Line 1: @@
-Intubating an awake patient with a fiberoptic scope after tropicalizing and numbing the oropharynx and glottic structures. Typically performed for suspected or known difficult airways or an unstable cervical spine.
+'''<big><u>Introduction</u></big>'''
-Equipment and setup:
+* Previously noted to be difficult intubation
-* lidocaine gel
-* 4% lidocaine
+'''<big><u>Anatomy/Innervation</u></big>'''
-* tongue blade wrapped in gauze, dipped in lidocaine gel.
-* 10cc syringe with 4% lidocaine with a 22g needle for transtracheal block
+* Glossopharyngeal Nerve
-* nasal cannula or face mask
+** Supplies innervation to the oropharynx, vallecula, and base of tongue
-* fiberoptic bronchoscope opened, tested, and set up
+* Vagus Nerve
-* glycopyrrolate or diphenhydramine to dry oropharynx
+** Provides innervation the posterior pharynx, vocal cords, and trachea via two major nerve branches (Superior Laryngeal Nerve + Recurrent Laryngeal Nerve)
-* consider sedation if neuro exam is less important, options include, midazolam, fentanyl, propofol, dexmedetomidine, or ketamine among others.
+*** Superior Laryngeal Nerve

Mitchel.DeVita: started page

2022-05-31T07:39:41Z

started page

← Older revision	Revision as of 00:39, 31 May 2022
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		Intubating an awake patient with a fiberoptic scope after tropicalizing and numbing the oropharynx and glottic structures. Typically performed for suspected or known difficult airways or an unstable cervical spine.

		Can be done via oral or nasal approach guided by nature of surgery, nature of difficult airway, or provider preference. Oral approach has several benefits including less overall distance, less bleeding risk, no need to dilate the nares, and typically quicker.


		Equipment and setup:

		* lidocaine gel
		* 4% lidocaine
		* tongue blade wrapped in gauze, dipped in lidocaine gel.
		* 10cc syringe with 4% lidocaine with a 22g needle for transtracheal block
		* nasal cannula or face mask
		* fiberoptic bronchoscope opened, tested, and set up
		* glycopyrrolate or diphenhydramine to dry oropharynx
		* consider sedation if neuro exam is less important, options include, midazolam, fentanyl, propofol, dexmedetomidine, or ketamine among others.

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2021-04-30T00:45:09Z

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