Anaes · Airway management

The anticipated difficult airway and the awake fibreoptic intubation

Also known as Awake fibreoptic intubation · AFOI · Awake intubation · Anticipated difficult airway · Topicalisation of the airway · Awake video laryngoscopy · Conscious intubation

The anticipated difficult airway is the airway that the preoperative assessment — the LEMON tool, the Mallampati class, the multi-factor scores — has flagged as likely to defeat direct or video laryngoscopy before induction is ever attempted. When the assessment is positive, the single safest strategy is usually to secure the airway while the patient is still awake, breathing, and protecting their own reflexes: the awake fibreoptic intubation (AFOI), the long-standing gold standard. The technique rests on four ideas examined here: the indication — predicted difficult laryngoscopy, aspiration risk where a rapid sequence is also unsafe, and the critically ill patient who cannot tolerate apnoea; the principle that the patient must remain cooperative and breathing throughout, so the pharmacology is built around topical anaesthesia and dexmedetomidine sedation rather than apnoea and paralysis; the six-step sequence of preparation, topicalisation, sedation, scope insertion, railroading of the tube, and confirmation before induction; and the honest framing of the alternatives — the awake video laryngoscope is faster and increasingly preferred, and in selected cases the airway can be avoided entirely with a regional technique. Anchored to contemporary evidence on the physiological difficult airway, the syndromic and neuromuscular difficult airway, the cerebral oxygenation and haemodynamic monitoring of the sedated patient, and the preoxygenation and oxygenation that make the awake technique safe.