I want to make the case for, perhaps, stepping outside of your comfort zone when you perform an awake fiberoptic intubation.

Face your patient. Doing so has several potential benefits.

1. A bronchoscopist facing their patient during an awake FOI necessitates elevating the head of the procedure table. It's easy to imagine why this positioning would be significantly less distressing, more comfortable and more favorable physiologically for a patient with airway pathology, an airway mass, and/or respiratory distress. Many of these patients probably do not want to lay supine, even if they can "tolerate" it.

2. Raising the head of the bed also takes advantage of gravity's forces, encouraging movement of lidocaine into the lower and more distal larynx and trachea.

3. Opinion - Facing the patient may also be helpful for the simple reason that it allows for more impactful communication and eye contact between provider and patient. The patient is no longer lying down having a procedure "done to them". The simple move of sitting the patient up and facing them morphs the patient into an active participant with their procedure.

Awake FOI with a supine patient

The alternative and more common approach - standing behind a supine patient during an awake FOI - is obviously more familiar for many anesthesia providers. And familiarity has value.

Flip the picture on its head - Reorienting yourself to new fiberoptic imaging which is different but the same.

It may be beneficial to simulate this "face the patient" positioning during a low stakes asleep FOI as the new orientation of structures on the video screen (flipped 180 degrees when a provider goes from standing behind a patient during a FOI to standing in front of them) can at first be disorienting.

There's rarely ever "one right way" to do anything, even (or especially) in medicine. Try out both methods and see what works best for you.

Happy fibering!