Awake Fiberoptic Nasotracheal Intubation

Primary Recommendations

The American Society of Anesthesiologists recommends awake fiberoptic nasotracheal intubation should only be performed by experienced clinicians in carefully selected patients with anticipated difficult airways, using meticulous preparation including head-up positioning, minimal sedation, adequate topical anesthesia, and active pre-oxygenation with high-flow nasal oxygen, while maintaining a clear backup plan for failure 1, 2

The American Society of Anesthesiologists indicates awake fiberoptic intubation is indicated when you anticipate a difficult airway AND one or more of the following apply: difficult mask or supraglottic airway ventilation is predicted, increased aspiration risk exists, patient cannot tolerate brief apneic episodes, or emergency front-of-neck access would be difficult or ineffective 3, 4

The British Journal of Anaesthesia suggests using appropriate nasotracheal tube, such as flexometallic, nasal RAE, or microlaryngeal tubes 5
The British Journal of Anaesthesia recommends positioning patient head-up to reduce aspiration risk and improve respiratory mechanics 1
The Anaesthesia journal suggests using direct application to nasal passages, oropharynx, and larynx for topical anesthesia 6

The Anaesthesia journal recommends advancing fiberoptic scope through prepared nostril under direct visualization and ensuring vocal cords are open and non-reactive before advancing scope or tube 6
The Anaesthesia journal suggests railroad nasotracheal tube over scope with gentle rotation if needed 5
The Anaesthesia journal recommends verifying tracheal placement with capnography before removing scope 2

The Anaesthesia journal advises limiting to maximum 3 attempts plus 1 additional attempt by most experienced operator, and if unsuccessful, following the unsuccessful awake intubation algorithm 2
The Anaesthesia journal recommends immediately calling for help, applying 100% oxygen, stopping and reversing any sedatives, and "stop and think" while priming for emergency FONA if awake intubation fails 2

The Anaesthesia journal suggests patients requiring awake fiberoptic intubation are at high risk for difficult extubation and require careful extubation planning following DAS extubation guidelines 2

The American Society of Anesthesiologists recommends performing systematic topical anesthesia of the airway using a combination of direct application to nasal passages, oropharynx, and larynx, supplemented by targeted nerve blocks to achieve complete anesthesia from the nares to the vocal cords 7
Targeted nerve blocks, such as glossopharyngeal nerve block, superior laryngeal nerve block, and transtracheal injection, can supplement topical techniques in challenging cases 8

The Difficult Airway Society guidelines suggest keeping patients nil by mouth for at least 2 hours following airway topicalization and monitoring total local anesthetic dose to avoid systemic toxicity 7
The American Society of Anesthesiologists recommends having difficult airway equipment immediately available, including videolaryngoscope, flexible bronchoscope, and supraglottic devices, and ensuring an individual trained in front-of-neck airway (FONA) techniques is present 8
The Anaesthesia journal guidelines suggest limiting attempts to maximum 3 attempts plus 1 additional by the most experienced operator and maintaining continuous pulse oximetry and capnography monitoring 7

The Difficult Airway Society guidelines recommend verifying tracheal placement with continuous waveform capnography before removing the fiberoptic scope and planning for high-risk extubation following Difficult Airway Society extubation guidelines 7, 9