Overview

Awake fiberoptic intubation (AFOI) is a technique for securing the airway in patients with known or suspected difficult airways while maintaining spontaneous ventilation and consciousness. It involves the use of a flexible fiberoptic scope to visualize and intubate the trachea.

AFOI is the gold standard for managing difficult airways in patients who cannot be safely intubated using conventional techniques. It maintains airway reflexes and spontaneous ventilation, reducing the risk of complete airway loss and allowing for patient cooperation.

Learn more in our comprehensive RxDx Anesthesia Course

Indications

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Known Difficult Airway

Previous failed intubation or known difficult airway

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Cervical Spine Injury

Unstable cervical spine requiring minimal manipulation

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Maxillofacial Trauma

Severe facial trauma with airway compromise

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Tumor or Mass

Upper airway tumors or masses

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Ankylosing Spondylitis

Severe neck immobility

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Previous Airway Surgery

History of airway reconstruction or surgery

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Severe Obesity

Morbid obesity with difficult airway

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Limited Mouth Opening

Trismus or limited mouth opening

Contraindications

Absolute Contraindications

✗ Patient refusal
✗ Complete airway obstruction
✗ Severe respiratory distress
✗ Uncooperative patient
✗ Severe bleeding in airway

Relative Contraindications

✗ Severe anxiety or panic
✗ Inability to cooperate
✗ Severe cardiovascular instability
✗ Recent airway trauma
✗ Severe coagulopathy

📋 Equipment Checklist

Check off items as you gather them:

Pre-procedure Preparation

Preparation includes thorough patient assessment (airway evaluation, psychological preparation), equipment check (fiberoptic scope, endotracheal tube, topical anesthesia), informed consent, and understanding the technique and backup plans.

Step-by-Step Procedure

Step 1: Patient Preparation

Explain the procedure, obtain informed consent, and prepare the patient psychologically.

⚠️ Common Mistakes to Avoid:

  • Poor explanation
  • Rushed consent
  • Inadequate preparation

💡 Pro Tip:

Take time to explain the procedure clearly. Patient cooperation is crucial.

Step 2: Topical Anesthesia

Apply topical anesthesia to the nose, oropharynx, and larynx using lidocaine spray and gel.

⚠️ Common Mistakes to Avoid:

  • Inadequate anesthesia
  • Wrong technique
  • Toxicity

💡 Pro Tip:

Use appropriate doses of local anesthetic. Monitor for toxicity.

Step 3: Anticholinergic Administration

Administer glycopyrrolate to dry secretions and improve visualization.

⚠️ Common Mistakes to Avoid:

  • Wrong timing
  • Inadequate dose
  • Side effects

💡 Pro Tip:

Give anticholinergic 10-15 minutes before procedure for optimal effect.

Step 4: Scope Preparation

Prepare fiberoptic scope, apply antifog solution, and load endotracheal tube.

⚠️ Common Mistakes to Avoid:

  • Broken equipment
  • Poor preparation
  • Wrong tube size

💡 Pro Tip:

Always test the scope before starting. Use appropriate tube size.

Step 5: Scope Insertion

Insert scope through nose or mouth and advance to the larynx under direct visualization.

⚠️ Common Mistakes to Avoid:

  • Poor technique
  • Wrong route
  • Trauma

💡 Pro Tip:

Advance scope gently. Use nasal route if possible for better patient comfort.

Step 6: Laryngeal Visualization

Identify vocal cords and advance scope through the glottis into the trachea.

⚠️ Common Mistakes to Avoid:

  • Poor visualization
  • Wrong identification
  • Esophageal intubation

💡 Pro Tip:

Look for the white vocal cords and the dark space between them.

Step 7: Tube Advancement

Advance endotracheal tube over the scope into the trachea and confirm position.

⚠️ Common Mistakes to Avoid:

  • Tube stuck
  • Wrong position
  • Inadequate confirmation

💡 Pro Tip:

Advance tube gently. Confirm position with multiple methods.

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Post-procedure Care

Post-AFOI care includes confirming tube position, monitoring for complications (airway trauma, bleeding), assessing for sore throat, and documenting the procedure details.

Complications & Management

Complication Incidence Signs Management Prevention
Local anesthetic toxicity 1-3% Seizures, arrhythmias, cardiovascular collapse Stop procedure, lipid emulsion, supportive care Use appropriate doses, monitor for toxicity
Airway trauma 2-5% Bleeding, pain, swelling, voice changes Stop procedure, assess severity, treat accordingly Gentle technique, proper lubrication
Failed intubation 5-10% Cannot visualize cords, multiple attempts, distress Call for help, use backup plan, consider alternatives Proper preparation, backup equipment
Patient distress 10-20% Anxiety, panic, uncooperative behavior Reassurance, sedation if needed, stop if necessary Good preparation, psychological support
Bleeding 1-3% Blood on scope, epistaxis, hemoptysis Stop procedure, apply pressure, assess severity Gentle technique, vasoconstrictors
Infection <1% Fever, sore throat, respiratory symptoms Antibiotics if needed, monitoring Proper scope cleaning, sterile technique

Clinical Pearls

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Patient cooperation is essential - take time to explain and prepare.

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Topical anesthesia is crucial - use appropriate doses and technique.

⚡

Practice scope manipulation regularly - skill improves with practice.

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Learn to recognize normal airway anatomy - it's essential for success.

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Have backup plans ready - AFOI can fail despite good technique.

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Use nasal route when possible - patients tolerate it better.

⚠️

Monitor for local anesthetic toxicity - it can be life-threatening.

🔄

Clean scope thoroughly after use - infection prevention is crucial.

📏

Use appropriate tube size - too large can cause trauma.

🎪

AFOI is a skill that requires regular practice and maintenance.