Introduction

An awake 'fiberoptic' intubation may be required in patients with a known or suspected difficult airway as a means to safely secure the airway prior to induction of anesthesia. This term is a misnomer for two reasons. Firstly, as we discuss in Modules 3 & 4, rarely is the patient completely 'awake' as this is usually unnecessary and undesirable. Secondly, most modern intubating bronchoscopes are video bronchoscopes, thus the term 'fiberoptic' should be replaced by 'flexible'.

An awake bronchoscopic intubation more literally translates to the use of a flexible bronchosope to place the endotracheal tube in a well topicalized, sedated and comfortable patient. Throughout this training program, the term 'flexible bronchoscope' is used to refer to both fiberoptic and video bronchoscopes.

Airway management has changed significantly over the past decade. The popularization and increased availability of video laryngoscopy, optical stylets and more sophisticated supraglottic airways have increased the options available to manage the patient with a difficult airway. However, awake bronchosopic intubation still holds an important place in managing the difficult airway and is still the most appropriate choice for some patients.

For many, the process of actually driving the scope through the upper airway into the trachea is the least daunting part of the technique. Unfamiliarity with topicalization and sedation is usually a greater source of hesitation. Anesthetists with particular expertise in awake bronchoscopic intubation will agree that a well prepared, appropriately topicalized and sedated patient lays the foundation for a successful bronchosopic intubation. The patient will tolerate the procedure far better, often without recall, and will be increasingly willing to consent to the same procedure on a subsequent occasion. All of these parts of the technique are covered in this website.