Advanced Airway Management
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Designed for real clinical practice.
awake
fiberoptic
intubation.
preparation.
targeted topicalization.
timing.
Most unsuccessful awake intubations are not caused by inadequate bronchoscopy skills. They result from inadequate airway preparation.
This guide focuses on the techniques, workflow, and decision-making that consistently lead to comfortable patients and successful intubations.
Performing an awake fiberoptic intubation can be one of the most rewarding—and one of the most intimidating—procedures in airway management. Even for experienced providers, these cases don't always go as smoothly as we'd like. There is also a common perception that awake intubations consume valuable operating room time.
While we should be honest with our patients that being intubated while awake is unlikely to be "fun," the alternative can be far worse. Choosing to forgo an awake fiberoptic intubation when one is truly indicated has the potential to be life-threatening, will almost certainly consume far more operating room time, and is decidedly not "fun" for anyone involved.
The good news is that most difficult awake intubations are not the result of inadequate bronchoscopy skills. More often, they stem from inadequate airway preparation, ineffective topicalization, excessive sedation, or an inefficient workflow. When these elements are optimized, awake fiberoptic intubation becomes a reproducible, efficient, and surprisingly well-tolerated procedure.
This guide is designed to help streamline your approach to awake fiberoptic intubation, making the entire process faster, smoother, and more comfortable—for your patient and for you.
Let's get started.
decision
point.
making the decision for an aFOI.
The more boxes you check, the stronger the indication for an awake approach. However, any single factor may be sufficient if the consequences of failed airway management after induction are unacceptable.
the 3 pillars
of
successful aFOI.
Patient & Equipment Preparation
Stage 1 (patient preOP prep)
-
Honest conversation
-
Consent
-
Set expectations
-
Dry airway
Stage 2 (OR prep)
-
Standard monitors
-
Supplemental O2
-
Suction
-
Bronch & airway equipment checked and ready
-
Topicalization equipment ready
-
Set stage for proper positioning of bronch and patient
Dense Airway Anesthesia
Reduce the need for compromise (i.e. oversedation, patient discomfort, LAST) with a nerve targeted and time conscious topicalization technique
-
Dense topicalization lasts 10-20 minutes (increasing to 2X with adequate mucosal drying)
-
Sequential, time efficient topicalization of CN IX, SLN & RLN in a dry airway
Bronchoscopy technique
In a well-prepared patient with a thoughtfully prepared airway, this is the easy part
-
Slow, steady movements
-
Centered targets
-
Appropriate size matchup between ETT & scope
aFOI
timeline.
t-30 minutes.
preparation.
1. Consent your patient
2. Then, immediately dry the airway
3. Set up OR & airway equipement
4. Calculate maximum safe lidocaine dose based on LBW
5. Prepare topicalization equipment
CONSENT
Be honest. Be direct.
Say something like,
"Mrs. Woody Neck, the stiffness and scarring around your neck and airway have us concerned that placing a breathing tube after you're asleep could be difficult. Because of that, we'd like to place the breathing tube while you're still awake and breathing comfortably on your own. That way, we know your airway is secure before we give you the medications that put you to sleep."
"To make this as comfortable as possible, we're going to thoroughly numb your nose, mouth, and throat. We'll also give you some medication through your IV to help you relax. Our goal isn't to put you to sleep just yet—we want you comfortable, calm, and breathing on your own throughout this part of the procedure."
"You may feel us working in the back of your throat, and you may feel some pressure or the urge to swallow, but you shouldn't feel pain. I'll be talking to you the entire time, letting you know exactly what we're doing, and if you need a moment, just let me know. Towards the very end of the procedure, you could notice a large urge to cough, that is a signal to you that we are almost done and are placing the breathing tube in your windpipe. We'll keep letting you know what we're doing as we're doing it."
"I know this probably isn't the part of your day you're looking forward to, but we're recommending it because we believe it's the safest way to care for you. We don't want to take unnecessary risks when it comes to protecting your airway and ability to breathe."
informed consent.
Patients are usually more anxious about not knowing what to expect than they are about the procedure itself. Clear explanations and realistic expectations often reduce anxiety more effectively than additional sedation or more limited consent styles.
aFOI
timeline.
t-20 minutes.
preparation.
1. Consent your patient
2. Then, immediately dry the airway
3. Set up OR
4. Calculate maximum safe lidocaine dose based on LBW
5. Prepare topicalization equipment
Dry the airway.
Give glycopyrrolate. ASAP.
This should be administered immediately after consent.
Why dry the airway?
Timing.
Why dry the airway?
Timing.
Increasing anesthetic effects from 10-20 to 30-40 minutes
Why dry the airway?
Better numbing.
With less lidocaine.
Secretions act as a barrier to lidocaine's effects.
Feeling rushed?
* Speed drying along by manually dabbing the posterior tongue with gauze
Onset of action.
Noticeable drying
~ 10 minutes.
Duration
7 hours
Why?
Better numbing.
With less lidocaine.
WAIT for a dry airway before starting topicalization
Dosing.
-
0.3 mg IV for average female
-
0.4 mg IV for average male
Glycopyrrolate contraindications
Acute angle glaucoma.
Otherwise mainly relative.
*If deleterious tachycardia is a concern, consider an esmolol drip over omitting glyco*
IM glycopyrrolate.
May have less tachycardic side effects
0.004 mg/kg IM
(onset time 15 min)
Glycopyrrolate for every aFOI.
Dries secretions. Prolongs denser topicalization window. Makes bronchoscopy easier.
aFOI
timeline.
t-15 minutes.
preparation.
1. Consent your patient
2. Then, immediately dry the airway
3. Set up OR
4. Calculate maximum safe lidocaine dose based on LBW
5. Prepare topicalization equipment
set
up
OR.
Along with your standard room setup, prepare and position all airway equipment before beginning any topicalization.
Remember that the most effective topical anesthetic effects of lidocaine are surprisingly short-lived—typically only 10–20 minutes in most patients. In contrast, serum lidocaine concentrations persist far longer and continue to accumulate with additional dosing.
Plan ahead. Have your equipment ready, your tube loaded, your bronchoscope functioning, and your airway strategy finalized before topicalization begins. Every delay after topicalization has begun erodes the brief window of dense airway anesthesia you have worked to create. The goal is to use the window of dense airway anesthesia—not spend it preparing for the procedure.
Streamline your setup. Streamline your efficiency.
Bronchoscope
tower.
Try a setup allowing you to face the patient.
1. Eye contact improves patient/provider communication
2. An elevated HOB improves comfort and lidocaine distribution in cases of SOB/stridor)
Bronchoscope.
ETT.
Size matchup matters.
POOR size matchup. Use a larger scope or a smaller ETT
Lubricant.
Silicone only.
Apply a light coating of silicone lubricant to ETT & scope.
Defogger.
Out & ready.
Apply a small amount to scope tip. Keep additional defogger nearby if reapplication needed later.
In a pinch, an alcohol swab works
Preload the bronchoscope.
Preload your selected ETT onto the largest scope over which it will fit
Oxygen.
Have nasal prongs ready for additional oxygenation during procedure.
Use a separate O2 source (green tank) for atomizer if using.
Oral airway.
It'll protect the bronchoscope and create an open conduit within the oropharynx to help guide your scope and ETT.
*If mouth opening is very limited, try to place a small soft bite block b/w molars
Ovassapian
Williams
Every piece of equipment should be ready before topicalization begins.
Delays after topicalization has already begun will SHRINK the dense topicalization window, which is already short-lived. This forces retopicalization, forces overreliance on sedation, or forces a motivated patient to "white-knuckle" an uncomfortable procedure.
aFOI
timeline.
t-15 minutes.
preparation.
1. Consent your patient
2. Then, immediately dry the airway
3. Set up OR
4. Calculate maximum safe lidocaine dose based on LBW
5. Prepare topicalization equipment
Lidocaine toxicity? In a difficult airway? No thank you.
There is no consensus on maximum lidocaine dosage when applied topically to the airway mucosa. The FDA recommendations (4.5 mg/kg LBW w/o epi; up to a 300 mg maximum dose) are for injection maxes and are not site specific. It is also important to note that toxicity has been demonstrated even with doses well below maximum recommendations. Thus, always take care to note those at heightened risk for local anesthetic toxicity and decrease accordingly. And as always, use the smallest dose necessary
know
the
do's
and
dose.
DAS
UK Difficult Airway Society (DAS) - Recommends a max topical dosage of 9 mg/kg lean body weight
True maximum dosing for topical lidocaine is unknown.
and dosing maximums varies by society.
ASA
Has no specific lidocaine dosing recommendations for awake fiberoptic intubations
mg/kg lidocaine dosing is based on lean body weight.
Calculate your patient's LBW here.
ASRA
“Systemic absorption from upper airway topical application is LOWER than expected, so in practice HIGHER doses can be used”
Factors associated with increased risk for toxicity.
-
Significant cardiac dz
-
Low cardiac output
-
Liver disease
Decrease lidocaine dosing accordingly.
Factors associated with increased risk for toxicity.
-
Extreme of age
-
Females
-
Gravid females
-
Low muscle mass
Decrease lidocaine dosing accordingly.
Factors associated with increased risk for toxicity.
Upper airway infections, URIs, & airway abscesses (increase mucosal vascularity, increasing absorption rates)
Decrease lidocaine dosing accordingly.
Lidocaine absorption and airway site.
Lidocaine absorption rates are lower in the upper airway (where numbing is most essential)
and higher in the lower airways
Lidocaine absorption by airway site.
Absorption rates in the alveoli do approximate IV injection.
* though topicalization of the lower airways is not necessary beyond the trachea.
200 mg applied to the tongue and posterior pharynx is not equivalent to 200 mg repeatedly delivered into the tracheobronchial tree.
aFOI
timeline.
t-15 minutes.
preparation.
1. Consent your patient
2. Then, immediately dry the airway
3. Set up OR
4. Calculate maximum safe lidocaine dose based on LBW
5. Prepare topicalization equipment
prepare
topicalization
equpment.
one suggested setup.
Ideal lidocaine concentration for topicalization.
3-5%
(2% is typically inadequate)
* Note that 1 inch of 5% lidocaine paste contains approximately 100 mg of lidocaine
for CN IX.
4x4 cotton gauze pledgets
Cut gauze in half and roll to make a small pledget. Coat with 1/2 inch of 5% lido paste
* Note CN IX which lies just superficial to mucosa of the posterior tonsillar pillar)
for SLN.
Combine 5% lido paste with surgical lube.
Administration aims to coat pyriform recesses.
for RLN.
4% Lidocaine Solution
Fill the atomizer with precalculated volume.
Fill 2 slip tip syringes with 3 mL's for use thru bronchoscope working channel.
the atomizer.
Great for top offs and hard-to-reach regions (RLN region, inaccessible tonsillar pillars/CN IX, etc)
Fill with 3-4% liquid lidocaine
the working channel.
Tip - Prefill each with 3cc of 3-4% lidocaine and 7 cc of air
the nebulizer.
Create a very fine mist, delivered to upper and lower airways. >50% is lost to the environment.
Does not typically create an incredibly dense field of numbness.
what is the best way to topicalize the airway?
at the end of the day, the best technique is the one any individual anesthesiologist is comfortable with.
aFOI
timeline.
t-10 minutes.
topicalize.
1. Transport to OR
2. Position patient, place monitors and oxygen
3. Topicalize CN IX
4. Topicalize SLN (CN X)
5. Place oral airway
6. Topicalize RLN (CN X)
sequentially topicalize.
timely, targeted topicalization..
Transport to OR. Position, place monitors & O2.
Position patient on OR table with HOB elevated. Place monitors. Place O2 nasal prongs.
Sedation - can be carefully titrated in small doses. Any complicated regimens should be assigned to a dedicated provider (not the proceduralist)
for CN IX.
~ when mouth opening is adequate ~
Ask patient to extend tongue and apply pledget to base of each tonsillar pillar x 2 min.
* Swallowing can cause nausea
(PO bioavailability 30%)
for CN IX.
*for inaccessible
tonsils
Use
atomizer
for SLN.
Drizzle viscous lidocaine down oropharynx by advancing catheter past base of tongue.
for SLN.
Another option - direct the atomizer nozzle 90 degrees to direct spray to each pyriform recess.
Located on either side of the epiglottis in the pyriform recess.
place oral airway.
Apply a thin coat of lidocaine paste to the oral airway.
Let the patient place it themselves. Tests for absence of the gag reflex and gives the patient a little autonomy.
the RLN.
Likely somewhat numb from aspirated lido.
Cords still mobile? spray lido thru working channel. Warn patient they may cough and prepare to
Remove scope and oral airway if necessary.
important to know.
Onset time for mucosal lidocaine is ~ 1-2 minutes. Plan accordingly to avoid premature airway instrumentation attempts, particularly when utilizing a "spray-as-you-go" techniquen thru the working channel.
aFOI
timeline.
t-2 minutes.
intubate.
intubate.
remember to.
Remain the calm & reassuring presence in the room that your patient is counting on
stay midline.
Keep your scope midline by keeping the oral airway centered in the midline.
center your targets.
a target centered on your screen is a target centered beneath your scope.
VCs lift anteriorly with coughing.
Aim your scope tip slightly towards the anterior commissure.
1
2
advance thru VCs.
Ask the patient to take a deep breath (it will open the glottis and elevate the epiglottis).
advance scope to carina & railroad ETT.
Once past the vocal cords, advance to the carina (exquisitely sensitive to instrumentation. Avoid direct contact.)
ETT stuck at the cords?
Withdraw the ETT 1-2 cm. Then readvance while simultaneously rotating the ETT.
Tip - good size matchup b/w ETT & scope is important here!
Once the ETT is in the trachea.
visualize the ETT tip within the trachea as you withdraw scope.
Midtracheal ETT - Leave about 5-6 tracheal rings b/w carina and ETT tip
3
Connect the ETT to the circuit, inflate cuff and confirm ETCO2.
Reassure the patient. Induce the patient with medications of choice.
Weigh Risks & Benefits
Inflating the ETT cuff will likely be stimulating . (potentially deleterious in an unstable C-spine or elevated ICP).
However, inflating cuff before induction rules out cuff damage
more scope tips.
For some simple tips on driving the bronchoscope, click here.
gentle jaw thrust.
Can help to maintain a midline position of the oral airway by preventing airway from "popping out".
video.
aFOI.
The awake fiberoptic intubation remains the gold standard for difficult airway management. It is therefore of vital importance that providers feel empowered to successfully perform this procedure in a variety of clinical settings, and to do so in a way that is both safe and expedient. We will continue to face mounting production pressure going forward, but patient safety need not be compromised. To this end, a streamlined technique, such as this, can be both fast and safe.
keep in mind.
Your patient will be taking their cues both from you and the others in the room. That being said, try to project a sense of calm confidence. Remind any trainees assisting you to do the same.
dive
deeper.
National and international awake airway management resources to compliment your practice.
NAP4 Project
1
The NAP4 Project identified numerous cases where an awake fiberoptic intubation was indicated but was not used. There were cases suggesting lack of skills, lack of confidence, poor judgement and in some cases lack of suitable equipment being immediately available. This latter problem was especially prevalent on ICU. Awake intubation should be used whenever it is indicated. This requires that anesthetic departments and individual anesthesiologists ensure such a service is readily available.
2022 ASA Difficult Airway Alhorithm
2
The American Society of Anesthesiologists’ (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to guide the anesthesiologist’s choice of pathway in the ASA’s Difficult Airway Algorithm. Entry into the awake intubation pathway is encouraged when the patient is judged at risk of difficult tracheal intubation and one or more of the following: difficult ventilation, significant aspiration risk, and/or rapid oxyhemoglobin desaturation.
2019 DAS ATI Guidelines
3
The 2019 Difficult Airway Society guidelines can offer a complimentary perspective for the approach to the awake tracheal intubation (ATI) in adults. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.