AWAKE FIBREOPTIC

INTUBATION
Presenter: Dr Muhammad Nur Amin b Abd Rahman
Supervisor: Dr Mohd Irwan b Mohd Rasidi
Difficult bag mask ventilations (MOANS)
Mask seal Bushy beards, crusted blood on face, disruption of lower
facial continuity
Obesity, Obstruction Obesity, pregnancy, angioedema, Ludwig’s angina,
upper airway abscess, epiglottis

Age Age > 55 years

No teeth Dentures

Sleep apnea, Stiff lung COPD, asthma, ARDS

Difficult laryngoscopy & intubation (LEMON)
Look externally Evidence of lower facial disruption, bleeding, small mouth, agitated patient

Evaluate 3-3-2 rule

1. Mouth opening (3 fingers)
2. Mandibular space; chin to hyoid (3 fingers)
3. Glottic space; hyoid to thyroid notch (2 fingers)

Mallampati score Class I-IV

Obesity, Obesity = poor glottic views

Obstruction 4 cardinal signs of airway obstruction:
1. Stridor
2. Muffled voice
3. Difficulty swallowing secretions
4. Sensation of dyspnea

Neck immobility Trauma, arthritis, ankylosing spondylitis; consider using VL

Difficult supraglottic device (RODS)
1. Restricted mouth opening
2. Obstruction
3. Disrupted or Distorted airway
4. Stiff lung, cervical Spine
Difficult cricothyrotomy (SHORT)
1. Surgery or other airway obstruction
2. Hematoma (include infection & abscess)
3. Obesity
4. Radiation distortion and other deformity
5. Tumour
Recommendations from 2020 Difficult Airway Society
guidelines for awake tracheal intubation (ATI) in adults

1. ATI must be considered in the presence of predictors of difficult

airway management.
2. A cognitive aid such as a checklist is recommended before &
during performance of ATI.
3. Supplemental oxygen should always be administered during ATI.
4. Effective topicalisation must be established & tested. Maximum
dose of lidocaine should not exceed 9 mg/kg lean body weight.
5. Cautious use of minimal sedation can be beneficial. This should
ideally be administered by an independent practitioner. Sedation
should not be used as a substitute for inadequate airway
topicalisation.
6. The number of attempts should be limited to three, with one further
attempt by a more experienced operator (3 + 1).
7. Anaesthesia should only be induced after a two-point check (visual
confirmation & capnography) has confirmed correct tracheal tube
position.
8. All departments should support anaesthetists to attain competency
& maintain skills in awake tracheal intubation.
Introductions

● ATI has a high success rate & a low risk profile & has been cited as
the gold standard in airway management for a predicted difficult
airway.
● ATI is reported to be used in as few as 0.2% of all tracheal intubations
in UK.
● A strategy for difficult airway management is necessary when
facemask ventilation, supraglottic airway device (SAD) placement/
ventilation, tracheal intubation/ insertion of a front-of-neck airway
(FONA) is predicted to be challenging.
● As a rescue technique after failed tracheal intubation, SADs have a
success rate as low as 65% in difficult airway management.
● The reported incidence of requirement for emergency FONA and
death due to airway management are 0.002–0.07% (1:50,000–
1:1400) and 0.0006– 0.04% (1:180,000–1:2800), respectively.
Surgical cricothyrotomy set - portex
Tracheostomy set - portex
● ATI involves placing a tracheal tube in an awake, spontaneously
breathing patient, with flexible bronchoscopy (ATI:FB) or
videolaryngoscopy (ATI:VL).
● This allows the airway to be secured before induction of GA, avoiding
the potential risk & consequences of difficult airway management in
an anaesthetised patient.
● ATI has a favourable safety profile because both spontaneous
ventilation & intrinsic airway tone are maintained until the trachea is
intubated.
● ATI can be unsuccessful in 1–2% of cases, but this rarely leads to
airway rescue strategies/ death.
Grading of recommendations from 2020 Difficult Airway Society guidelines for ATI in adults

Grade Level of evidence available

A Consistent systematic reviews of RCT’s, single RCT’s/ all or none studies

B Consistent systematic reviews of low quality RCT’s/ cohort studies, individual cohort study/
epidemiological outcome studies
Consistent systematic reviews of case-control studies/ individual case-control studies
Extrapolations from systematic reviews of RCT’s, single RCT’s/ all or none studies

C Case series, case reports

Extrapolations from systematic reviews of low quality RCT’s, cohort studies/ case-control
studies, individual cohort study, epidemiological outcome studies, individual case-control
studies
Extrapolations from systematic reviews of case-control studies

D Expert opinion/ ideas based on theory, bench studies/ first principles alone
Troublingly inconsistent/ inconclusive studies of any level
Indications
Common features that have been identified in patients requiring ATI
includes, but are not limited to:
1. patients with head and neck pathology (including malignancy,
previous surgery/ radiotherapy)
2. reduced mouth opening
3. limited neck extension
4. obstructive sleep apnoea
5. morbid obesity
6. progressive airway compromise
Airway assessment including history, examination and appropriate Ix, is
indicated for all patients (Grade D)
ATI must be considered in the presence of predictors of difficult airway
management (Grade D)
In an elective setting the patient should be appropriately fasted (Grade D)
In the non-fasted patient, the potential for regurgitation or aspiration of
gastric contents still exists even with ATI
Contraindications

● Relative contraindications: local anaesthetic allergy, airway bleeding,

uncooperative patients.
● Absolute contraindication: patient refusal.
Procedural setup

Safety should not be compromised by time pressures presented by other

staff members; therefore planning & communication with anaesthetic
assistants, OT nursing staff, surgeons and skilled anaesthetic colleagues
is essential (Grade D)
ATI should ideally be performed in the OT environment (Grade D) with
ready access to skilled assistance, drugs, equipment & space
When ATI is performed outside of the OT environment (e.g. in ICU/ ED),
the same standards of care should apply (Grade D)
For patient receiving sedation, it is recommended that ECG, NIBP, pulse
oximetry & continuous ETCO2 monitoring are used throughout the
process of ATI (Grade C)
Workspace ergonomics have an impact on performance & safety and
should be considered before starting the procedure (Grade D)
Ergonomics for ATI
ATI performed with the operator
positioned facing the patient who is
in a sitting up position
Ergonomics for ATI
ATI performed with the operator
positioned behind the supine/
semire-cumbent patient
Complications/ unsuccessful ATI, although uncommon, should be
prepared for, and immediate access to emergency drugs, staff &
equipment is essential (Grade C)
A plan for unsuccessful ATI, including postponement, FONA/ high-risk GA
should be discussed explicitly & agreed on by all team members before
beginning the procedure (Grade D)
Route for tracheal intubation should take into account patient anatomy,
surgical access & tracheal extubation plan (Grade D)
For example, in patients with limited mouth opening, the nasal approach
may be the only option, while in patients having nasal surgery, the oral
approach may be the preferred route
There is no evidence demonstrating superiority of one route if both are
feasible
ATI:VL has a comparable success rate and safety profile to ATI:FB
(98.3% each)
Choosing between techniques is based on patient factors, operator skills
& availability of equipment (Grade A)
For example, in patients with limited mouth opening, a large tongue/ fixed
flexion deformity of the neck, ATI:FB may be more appropriate.
Conversely, patients with airway bleeding may be more suitable for an
ATI:VL.
If the chosen ATI technique is unsuccessful, consider using an alternative
e.g. ATI:FB if ATI:VL is unsuccessful or vice versa; (Grade D)
A combine approach could be considered in complex clinical scenarios
(Grade D). In well topicalised patient, SAD as a conduit for ATI:FB has
also been described
Operators should defer to local availability & personal experience in
determining which flexible bronchoscope to use (Grade B)
There is no evidence or consensus to support the safety/ efficacy of any
VL
For ATI:VL practitioners should use VL with which they are most familiar
(Grade B)
Careful selection of tracheal tube is integral to the success of any ATI
technique
This should factor in size (internal & external diameter), shape, length, tip
design & material
For ATI:FB, reinforced, Parker Flex-TipTM & intubating LMA tubes (LMA
FastrachTM ETT) have been shown to be superior to standard PVC
tracheal tubes in terms of ease of tracheal intubation, railroading
(advancing the tracheal tube over the flexible bronchoscope) &
decreasing laryngeal impingement. Therefore, the use of a standard PVC
tracheal tube is not recommended (Grade A)
Using the smallest appropriate external diameter tracheal tube is
advisable, as this may reduce the incidence of impingement (Grade B)
Positioning the bevel of the tracheal tube posteriorly is recommended
(Grade A)
The key components of ATI are sedation, topicalisation, oxygenation &
performance (sTOP). The ‘s’ is in lower case to emphasise the optional
nature of sedation.
Sedation

The risk of over-sedation & its sequelae, including respiratory depression,

airway loss, hypoxia, aspiration & cardiovascular instability, make the
presence of an independent anaesthetist delivering, monitoring & titrating
sedation desirable (Grade D)
Remifentanil & dexmedetomidine are a/w high levels of patient
satisfaction & low risk of oversedation and airway obstruction when used
for ATI. A single-agent strategy is safest & if used, either remifentanil/
dexmedetomidine are appropriate (Grade A)
Target controllled infusion (TCI) Remifentanil (ultra short acting opioid)
can provide good intubating conditions, is well tolerated & has high
patient satisfaction scores.
The advantage of dexmedetomidine (a2 agonist) is that a state of
cooperative sedation is achieved; it also has antisialagogue effects. There
is level 1 evidence to support its use for good intubating conditions,
patient tolerance & patient satisfaction. 
Propofol can be administered as intermittent boluses or as an infusion.
There is now increasing popularity of administering propofol as a TCI,
either as a sole agent or in combination with remifentanil.
However, the balance between underdosing (which may be associated
with coughing and movement) & overdosing (with airway obstruction and
loss of cooperation) can be difficult to achieve.
Benzodiazepines are usually administered in combination with an opioid
as intermittent boluses and have been used as a sedative for ATI. The
disadvantage of using boluses of benzodiazepines are associated with
overshooting; therefore, there is a risk of oversedation and apnea.
Sedation should not be used as a substitute for inadequate airway
topicalisation (Grade D)
Airway topicalisation

The success of ATI depends on effective topical application of LA to the

airway.
The use of topical nasal vasoconstrictors before nasotracheal intubation
is recommended (Grade A). This help to reduce the incidence of
epistaxis.
Lidocaine has favourable CVS & systemic toxicity risk profile over other
LA agents and is the most commonly used LA for ATI.
The dose of topical lidocaine should not exceed 9 mg/kg lean body weight
(Grade C)
The total dose of all LA’s administered, regardless of route (e.g. RA/
surgical infiltration), must also be considered (Grade D)
As with all local techniques, a high index of suspicion of the rare
possibility of LA toxicity with appropriate training, procedures &
emergency drug provision (including lipid emulsion) should be in place
(Grade D)
Initial bolus of 1.5 mL/kg 20% lipid
emulsion followed by 0.25 mL/kg
per minute of infusion, continued for
at least 10 minutes after
circulatory stability is attained is
recommended.
The use of cocaine for topicalisation & vasoconstriction can be a/w toxic
cardiovascular complications, while its analgesic efficacy during
nasotracheal tube insertion is no better than co-phenylcaine (2.5 ml
lidocaine 5%/ phenylephrine 0.5%).
Cocaine in this setting is therefore not advised & phenylephrine in
combination with lidocaine is more appropriate (Grade A)
There is insufficient evidence to recommend any individual topicalisation
technique (e.g. mucosal atomisation, spray-as-you-go, transtracheal
injection, nebulisation).
However, blocks of the glossopharyngeal & superior laryngeal nerves
have been a/w higher plasma concentrations of LA, LA systemic toxicity &
lower patient comfort.
Invasive techniques should therefore be reserved for those with expertise
in their performance (Grade B)
Airway blocks technique

1. Glossopharyngeal nerve block (landmark technique)

Blocks sensation to the posterior third of the tongue & the vallecula &
blocks the sensory limb for the gag reflex.
There are two approaches described for this: intraoral & peristyloid.
Intraoral approach requires sufficient
mouth opening to allow adequate
visualization & access to the base of
the posterior tonsillar pillars
(palatopharyngeal arch).
After adequate lidocaine spray, the
tongue is retracted medially with a
laryngoscope blade or a tongue
depressor, allowing access to the
posterior tonsillar pillar.
2-5 ml of 2% lidocaine are injected submucosally after negative
aspiration.
The point of injection is at the caudal aspect of the posterior tonsillar pillar
(approximately 0.5 cm lateral to the lateral edge of the tongue where it
joins the floor of the mouth)
Alternatively, a gauze soaked in LA can be firmly applied for a few
minutes.
Peristyloid approach aims to infiltrate LA just posterior to the styloid
process where the glossopharyngeal nerve lies.
In close proximity is the internal carotid artery.
The patient should be placed in a supine position with the head placed
neutrally.
The styloid process is located at the midpoint of a line drawn from the
angle of the jaw to the tip of the mastoid process.
A needle is inserted perpendicular to the skin, aiming to hit the styloid
process.
Once contact has been made (usually 1–2 cm deep), the needle should
be reangled posteriorly and walked off the styloid process until contact is
lost, then 5–7 mL of 2% lidocaine can be injected.
2. Superior laryngeal nerve block (landmark technique)
Blocks sensation to the laryngeal structures above the vocal cords
(VC) and lies inferior to the greater cornu of the hyoid bone; here, it
splits into the internal & external branches.
The superior laryngeal nerve can be blocked using the external or internal
approach.
Using the external approach, the patient is placed in the supine position
with a degree of neck extension to facilitate identification of the hyoid
bone.
Once identified, the hyoid bone is gently displaced to the side where the
block is to be performed & a needle is inserted from the lateral side of the
neck, aiming toward the greater cornu.
Once contact has been made, the needle is walked off the bone inferiorly
& injecting 2 mL of 2% lidocaine here will block both the internal & the
external branches of the superior laryngeal nerve.
If the needle is advanced a few millimeters, it will pierce the thyrohyoid
membrane, and a “give” is felt. Injecting LA here will result in only the
internal branch of the superior laryngeal nerve being blocked.
Careful aspiration must be performed prior to injection, especially as the
carotid artery is in close proximity.
The internal approach uses gauze soaked in LA & placed in the piriform
fossae using forceps for 5-10 minutes to allow sufficient time for the local
anesthetic to take effect.
3. Recurrent laryngeal nerve block (landmark technique)
It supplies the sensory innervation of the VC & trachea.
It also provides the motor supply to all the intrinsic muscles of the
larynx except the cricothyroid muscle.
Direct recurrent laryngeal nerve blocks are not performed as they can
result in bilateral VC paralysis & airway obstruction, as both the motor
and the sensory fibers run together.
Therefore, this nerve is blocked using the translaryngeal block.
The patient should be supine, with the neck extended be identified in the
midline, then the cricoid & thyroid cartilage is palpated.
The cricothyroid membrane lies between these two structures.
One hand should stabilize the trachea, then a needle should be inserted
perpendicular to the skin with the aim to penetrate the cricothyroid
membrane.
This should be done with continuous aspiration of the syringe, as the
appearance of bubbles will indicate that the needle tip is now in the
trachea.
At this point, immediately stop advancing the needle; otherwise, the
posterior laryngeal wall can be punctured.
Rapid injection (and then removal of the needle) of 5 mL of 4% lidocaine
will result in coughing, which will help to disperse the LA & blockade of the
recurrent laryngeal nerve.
Regardless of technique used, the adequacy of topicalisation should be
tested before airway instrumentation (Grade D) for example, with a soft
suction catheter/ Yankauer sucker.
The use of an antisialogogue is not mandatory & may a/w undesirable
clinical consequences (Grade D)
There is limited evidence to support their use in ATI, but in anaesthetised
patients the clarity of a visual field through a FB may be improved.
Oxygenation

The administration of supplemental oxygen during ATI is recommended

(Grade B)
This should be started on patient arrival for the procedure & continued
throughout (Grade D)
If available, high-flow nasal oxygen should be the technique of choice
(Grade C)
Performance
Two point check of tracheal tube placement

1. Visualisation of the tracheal lumen with ATI:FB/ the tracheal tube

through the vocal cords with ATI:VL
2. Capnography to exclude oesophageal intubation (Grade C)
Anaesthesia should be induced only when the two point check has
confirmed correct tracheal tube placement (Grade D)
Once the flexible bronchoscope is in the trachea, the carina should be
identified before advancing the tracheal tube to minimise the risk of
misplacement (Grade D)
The distance from the tracheal tube tip to the carina should be confirmed
as appropriate before removing the bronchoscope (Grade D)
Patients in whom ATI is indicated such as airway trauma, airway
obstruction, bleeding & unsuccessful ATI are at greater risk of the adverse
consequences of multiple attempts of ATI. It is advisable to minimise the
number of attempts at ATI (Grade D)
Operators should consider if they require more experienced support
before commencing ATI (Grade D)
If unsuccessful with the 1st attempt, operators should reassess and call
for help before proceeding with a 2nd attempt (Grade D)
If unsuccessful with the 2nd attempt, a 3rd may be considered only if
conditions can be further optimised (Grade D)
A 4th & final attempt (3+1) should only be undertaken by a more
experienced operator which may include surgeon (Grade D)
The unsuccessful ATI algorithm is a guide for the rare occasions where
successful tracheal intubation has not been achieved in 3 + 1 attempts.
Immediate actions should include a call for help, ensuring 100% oxygen is
applied & stopping (if necessary, reversing) any sedative drugs (Grade D)
Operators should ‘stop & think’ to determine subsequent airway
management, while also ‘priming’ for emergency FONA (Grade D)
The default action in the event of unsuccessful ATI should be to postpone
the procedure (Grade D)
Operators should only proceed with immediate airway management if
essential (e.g. if airway patency, ventilation or neurology is compromised;
urgent or immediate surgery is required; or clinical deterioration is
expected) (Grade D)
The preferred option for securing the airway after unsuccessful ATI:VL/
ATI:FB should be FONA which includes cricothyroidotomy/ tracheostomy
(Grade D)
The most appropriately skilled clinician available should perform this
(Grade C)
Documentation of ATI in clinical records is necessary to inform & guide
future patient management. This should include: documentation of
oxygenation; topicalisation; sedation strategy; device & tracheal tube
used; approach (e.g. right nasal, left nasal, oral); number of attempts; &
any complications/ notes (Grade D)
Standard practice of preparation for ATI in HTAA

● Thorough pre procedure/ pre operative assessment & explanation

● High risk consent
● Alerting ENT collague + tracheostomy consent
● OT preparation (GA machine, staffs, difficult airway trolley, list of
medications, infusions, suctioning apparatus, post procedure/ post
operative ICU / ventilator back up)
● Medications includes emergency drugs, aspiration prophylaxis,
antisialagogue (200mcg iv glycopyrollate), neb lidocaine 2% 4ml,
cocaine for topical anaesthesia of the nasopharynx, nasopharyngeal
airway with lignocaine gel, remifentanil/ precedex infusion, “spray as
you go” lidocaine 2% 5ml in 3 separated 10ml syringe and iv
induction agents.
● Procedure performed by anaesthetist incharge/ under anaesthetist
supervision.
● Difficult airway data book & card.
Modified guedel’s airway with bite block & method of insertion of
bite block into the airway
Berman’s airway, william’s airway, ovassapian’s airway
Reference

2020 Difficult Airway Society guidelines for awake tracheal intubation

(ATI) in adults by I. Ahmad et al
Regional and Topical Anesthesia for Awake Endotracheal Intubation,
www.nysora.com by I. Ahmad