ICU · Airway management

Awake Fibre-Optic Intubation

Also known as Awake fibre-optic intubation · AFOI · Awake intubation · Fibre-optic intubation · Topical airway anaesthesia · Spray-as-you-go · Cooperative sedation · Dexmedetomidine for intubation · Local anaesthetic airway · Superior laryngeal nerve block · Glossopharyngeal nerve block · Anticipated difficult airway

Awake fibre-optic intubation (AFOI) is the safest approach to the anticipated difficult airway when the patient can cooperate and maintain oxygenation: topicalise the upper airway with local anaesthetic, sedate lightly so the patient stays breathing with airway reflexes preserved, navigate a flexible scope through the cords on inspiration, and railroad an endotracheal tube. The principle is that the patient never loses their airway. Indications are a predicted difficult airway (prior difficulty, cervical instability, limited mouth opening, distorted anatomy, head-and-neck mass, obesity, risk of 'can't intubate, can't ventilate'); contraindications are inability to cooperate, inability to tolerate apnoea, complete upper-airway obstruction, an airway flooded with blood or secretions, and local-anaesthetic allergy. Technique: topicalisation with lidocaine 1–4% (spray, nebulised, gargle, paste, or spray-as-you-go), optional nerve blocks (superior laryngeal and glossopharyngeal), cooperative sedation with dexmedetomidine or remifentanil target-controlled infusion, scope handling, and railroading of the ETT over the scope. Complications include laryngospasm, local-anaesthetic systemic toxicity (LAST), and airway trauma.