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.