Awake Fiberoptic Intubation. Why is it Done?

awake fiberoptic intubation Awake fiberoptic intubation can be an effective solution in securing a patient’s airway due to difficult airway and in cases where conventional intubation is not an option.

A difficult airway refers to a clinical situation whereby a healthcare provider faces challenges with one or more recognized techniques for airway management.

In this scenario, or when a patient has a history of difficult mask ventilation or intubation, awake fiberoptic intubation can be a safe and effective course of action. This is particularly true for patients for whom the loss of frank apnea can be catastrophic.

Let’s explore awake fiberoptic intubation as a procedure for addressing difficult airways.

What Is Awake Fiberoptic Intubation?

Awake fiberoptic intubation, or AFOI, is an effective airway management technique for patients who have difficult airway and have anticipated issues with conventional mask ventilation and intubation.

This technique provides a clear visualization of the vocal cords through a flexible nasal or oral route, with an endotracheal tube being passed into the trachea under direct vision.

Healthcare providers looking to perform AFOI must be familiar with the anatomy of the normal upper and lower airways. This includes the nasal passage, the larynx and the trachea’s carina/bifurcation. 

Knowledge of the maximum dosages of local anesthetics is also required as these are commonly employed during an awake fiberoptic intubation procedure.

It is also essential for a clinician to have a clear and defined management plan for addressing a difficult airway scenario whether predicted or unpredicted.

What Is a Difficult Airway?

A difficult airway is typically described as a clinical situation during which a clinician experiences difficulties related to face mask ventilation, supraglottic device ventilation, tracheal intubation, or all three.

When utilizing direct laryngoscopy, two or more failed attempts at intubation with the same or different blade may be described as a difficult airway. This is also the case when adjuncts or alternative devices or techniques are used, following a failed intubation with direct laryngoscopy.

All of these situations point to what is known as a difficult airway, whereby a medical practitioner has difficulties securing an airway for respiration. An awake fiberoptic intubation is thus performed in difficult airway situations whereby safe ventilation and oxygenation cannot be achieved with satisfactory results. An awake fiberoptic intubation thus offers a safe, effective, and secure solution for establishing airway passages.

Why Is Fiberoptic Intubation Done Awake?

A predicted difficult airway or a patient with an unstable cervical spine can be cause for concern as they can lead to major respiratory issues. Conventional direct laryngoscopy using a sniffing position can cause spinal cord injury in such situations and therefore not recommended. DL with cervical immobilization poses several risks or may be wholly impossible. This is especially true in situations where:

  • A difficult airway has been previously established.
  • There have been previous difficulties in ensuring mask ventilation.
  • There is the potential risk of a difficult away, determined during preassessment, in addition to other complicating factors such as an inability to access the pre-cricoid or pre-tracheal region, aspiration risk, or complexities with the use of inhalational anesthetic agents.
  • The rid of iatrogenic injury needs to be mitigated, particularly in patients with an unstable C-spine caused by rheumatoid arthritis, trauma, etc.

Fiberoptic intubation is not only an effective solution in these instances, but it also significantly reduces the risk of aspiration. This is because the intubation technique enables patients to maintain their own airway, from preparation until successful, satisfactory intubation is achieved. 

Under this method, there is no need to manipulate the cervical spine either. The procedure can also be safely abandoned in the unforeseen and unlikely event that some complications arise at any stage.

Overall, by performing the fiberoptic intubation while the patient is awake and conscious, medical practitioners are able to successfully ensure intubation while reducing certain major risks associated with respiratory problems and difficult airways.

Guidelines for Performing an Awake Fiberoptic Intubation

AFOI has a low-risk profile and high rates of success when performed correctly. Here are some guidelines to ensure that the intubation is performed properly:

  • Predictors of difficult airway management must be thoroughly considered.
  • A checklist or other cognitive aid can be helpful before and during the procedure and is therefore recommended.
  • Supplemental oxygen must be administered throughout the course of the procedure.
  • The maximum dose of lidocaine must be equal to or less than  9 mg/kg based on lean body weight and effective topicalization must be tested and established.
  • Minimal sedation when used cautiously can be highly beneficial and should be administered by an independent practitioner. IV ketamine is a great choice since it does not suppress respirations. Sedation cannot be used in place of inadequate airway topicalization.
  • Awake fiberoptic intubation must be limited to three attempts. In case one more attempt is required, a more experienced clinician may perform it, thereby making the total attempts 3+1.
  • Anaesthesia may only be induced after a correct tracheal tube position has been confirmed by checking two points: capnography and visual confirmation.
  • All departments involved in the procedure must support the anesthetists in achieving competency and maintaining their skills in AFOI.

By keeping these guidelines in mind and adhering to them as much as possible, it is possible to successfully perform fiberoptic intubation with little risk to the patient.

Final Thoughts

Awake fiberoptic intubation is an effective and safe technique that can be utilized when a patient has a challenging airway anatomy that needs to be secured. It is also an effective solution for anticipated difficulties that may arise during conventional intubation.

Since this procedure is performed while the patient is awake and maintains spontaneous breathing, it ensures optimal airway control and is relatively safer.

Awake fiberoptic intubation is an invaluable tool to ensure successful airway management in complex clinical scenarios. Check our courses to find the one that best suits your needs. Our professionals are ready to teach you the most up-to-date techniques. 


Ramkumar, V. Preparation of the patient and the airway for awake intubation. Indian J Anaesth. 2011 , 55(5): 442–447
Rosenstock, C. Thogersen, B. Afshari, A. Chistensen, Anne-Lise. Awake Fiberoptic or Awake Video Laryngoscopic Tracheal Intubation in Patients with Anticipated Difficult Airway Management: A Randomized Clinical Trial. Perioperative Medicine. 2012

Read all articles in Endotracheal Intubation, Featured, Hospital Procedures

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