Awake fibreoptic intubation (AFOI) - My approach





This is my preferred approach

Decision

➤ Nasal approach

➤ Conscious sedation

  • Midazolam IV
  • Remifentanil infusion

➤ Topical anaesthesia

  • Cocaine for nasal passage and nasopharynx
  • 4% lignocaine for larynx
    • To be injected through cricothyroid membrane

Preparation

MADE

➤ Monitoring

  • Standard monitoring
  • Supplemental O2 by Hudson mask

➤ Assistance / access

  • Have more than one assistant
  • IV access
  • Identify and mark cricothyroid membrane
    • Consider shoulder roll to extend the neck

➤ Drugs (VAST)

  • Vasoconstrictor
    • Cocaine mixed in with gel / lubricant
    • Co-phenylcaine (esp if not using cocaine)
  • Antisialogogue
    • Glycopyrrolate 200 mcg IV
  • Sedation drugs
    • Midazolam
    • Remifentanil infusion
  • Topical anaesthetics
    • Lignocaine 4%

➤ Equipments

  • Long 20G IV cannula
    • Long cannula minimises the chance of dislodgement when patient coughs or swallows
  • Fibreoptic bronchoscope
  • Nasopharyngeal airways (6mm, 7mm)
  • Size 6 reinforced ETT
  • Suction
  • Intubating equipements
  • Cricothyroidotomy kit

Steps

  1. Commence remifentanil infusion

    • Starting at 0.05 mcg/kg/min
    • Up to 0.20 mcg/kg/min

  2. Give premed

    • Midazolam IV (1 to 2.5mg)
    • Glycopyrrolate 200 mcg IV

  3. Dilation and topical anaesthesia of nasal passage

    • Use nasopharyngeal airway
      • Start with 6 mm, then change to larger size (7mm)
    • Lubricate with gel mixed with cocaine (100mg)
    • Leave in until ready for ETT

  4. Topical anaesthesia of larynx

    • Identify cricothyroid membrane
    • Cannulation
      • LA to skin
      • Insert a 20G cannula through while aspirating with a syringe
      • Advance the cannula when air aspirated. Discard needle
    • Topicalisation of larynx and trachea through cannula
      • Inject 2 to 3 mL of 4% lignocaine after aspirating air
      • Allow patient to cough and spit
      • Repeat after 3 minutes or so
        • Stop when cough reflex abolished
      • May require 3 to 4 doses in total

  5. Insert reinforced ETT through the nose

    • Stop when black lines disappear
    • Lubricate with cocaine-containing gel

  6. Fibreoptic bronchoscopy

    • Visualise vocal cord
      • ETT may need to be advanced further to help navigating through nasopharynx
    • Advance the scope through the cords
    • If no cough reflex is elicited, insert ETT through
      • Rotate ETT and slowly advance

  7. Verify

    • Remove FOB and connect circuit
    • Verify CO2 trace
    • Verify carina and ensure tracheal (not bronchial) intubation
      • i.e. Attempt to identify the 3 branches off the right main bronchus

  8. Induction

    • Induce patient

NB:

Leave the cannula in the cricothyroid membrane if possible

  • Allows repeat dosing of topical anaesthesia
  • Allows easier and faster identification of landmark for surgical airway
  • Allows the possibility of retrograde intubation as an escape plan

(However, often the cannula may become displaced when patient coughs or swallows.)