Regional Anesthesia of the airway for Awake Fiber-optic Intubation

Abstract

Awake intubation is usually performed in the presence of a difficult airway. It is an essential skill in the management of a patient with a known difficult airway or who has an anticipated difficult airway as found during the airway assessment preoperatively. It is important to know the anatomy of the normal upper and lower airway, from the nasal passage to the carina/bifurcation of the trachea. It is also essential to have a good knowledge of the mechanisms of action and maximum dosage of various local anesthetic agents as they are used widely in this technique. When faced with an anticipated difficult airway, the anesthesiologist needs to consider securing the airway in an awake state without the use of anesthetic agents or muscle relaxants. As this can be highly discomforting to the patient, time and effort must be spent to prepare such patients both psychologically and pharmacology for awake intubation. Psychological preparation is best initiated by an anesthesiologist who explains the procedure in simple language. Sedative medications can be titrated to achieve patient comfort without compromising airway patency. Additional pharmacological preparation includes anesthetising the airway through topical application of local anesthetics and appropriate nerve blocks. When faced with a difficult airway, one should call for the difficult airway cart as well as for help from colleagues who have interest and expertise in airway management. Preoxygenation and monitoring during awake intubation is important. Anxious patients with a difficult airway may need to be intubated under general anesthesia without muscle relaxants. Proper psychological and pharmacological preparation of the patient by an empathetic anesthesiologist can go a long way in making intubation acceptable for all concerned.