• depends on operator expertise + equipment + location of obstruction
• potential for complete AW obstruction
• Common pitfalls
  • Touching the walls and creating cough
  • Rushing, and not taking it slowly
• My tips from 1st awake FOI (with sedation)
  • Go slow with sedation, easier than waiting for patient to lighten up
  • Vocal cords are anterior to oesophagus so (standing in front to patient's left), will be on BOTTOM half of screen
  • Suction works and is great
  • Spray as you go with O2 tubing and gravity giving set
  • Use HFNP, great for oxygenation
  • Main points = smaller Berman, slow sedation titration, use suction, HFNP

• I'm going to use ...
• I need to use ...
• An advanced airway technique because I'm concerned about going off to sleep

• can't open mouth
• known / suspected difficult BMV
• known / suspected difficult intubation
• unstable C-spine
• isolation of leak + lung protection prior to PPV, eg. bronchopleural fistula

• risk of complete AW obstruction
• high risk bleeding
• gross anatomical distortion
• uncooperative patient
• operator inexperience

• Airway obstruction!!
  • Cork in the bottle phenomenon with very narrow trachea

• Nerves = CN V, IX, X
• Nasopharynx
  • Anterior nasal cavity = anterior ethmoidal nerve (CN V1)
  • Remainder nasal cavity = CN V2 = palatine N
• Oropharynx = CN V, IX, X
  • Primarily CN IX Glossopharyngeal
• Larynx = X
  • Above vocal cords = internal branch superior laryngeal N (CN X)
  • Vocal cords = RLN (CN X)
  • Below vocal cords = RLN

• IV access + standard monitoring + assistant + emergency drugs
• premedication
  • anti-sialologue
  • sedation = midaz / remifentanil / propofol
• supplemental O2
• ensure anaesthetic induction agent + NMBA drawn up
• topical lidocaine
  • max = 7-9 mg/kg
• bronchoscope
  • preloaded with ETT
  • advance
• confirm position with FOB
• induce / deepen anaesthesia
• inflate cuff
  • cuff of inflation is stimulating and unpleasant
  • sensation of proprioception is intact, feels like asphyxiation
• paralysis

• Portex = Blue nasal ETT
• Fastrach 6.5 is best
• Much better visuals with FOB

• "I would topicalise with a combination of spray and gel, with a maximum dose of ___ mg"
• "Targeting these structures"
• "With a spray-as-you-go technique"
• co-phenylcaine spray to nasal cavity
• transtracheal LA
• superior laryngeal N block (rarely used)
  • 0.5 cm caudal to cornu of hyoid bone
• glossopharyngeal N block
  • rarely used bc carotid puncture

• Great for oral intubations
• If unable to advance further back, may be too large
• If too large, the first black hole will be the oesophagus
• Difficult insertion if hard collar on

• Bronch setup
  • 5.2 Storz
  • O2 tubing, spike with a giving set, connected to a chook's foot
  • This is from
  • No need for suction, it's ineffective
• 10% lignocaine GEL onto Berman airway
  • Top up with lignocaine viscus on "missed spots"
  • Endpoint = able to tolerate the Berman in situ
• Transfer to OT bed
• Screen on patient's left, stand on patient's right
• Don't touch the pharynx, it will provoke cough
• Sedation = Remi 1-2.0
• LA = 1% lignocaine with Ad in 1 mL syringes
  • Is also great at clearing screen

• https://www.orsim.com/
• AirSim = https://trucorp.com/product/airsim-difficult-airway/

https://www.nysora.com/techniques/head-and-neck-blocks/airway/regional-topical-anesthesia-awake-endotracheal-intubation/

Awake intubation

https://openairway.org/airway-topicalisation-how-to-make-the-gsh-mix/