Fibreoptic intubation in awake patients.

Background: Awake fibreoptic intubation has been recommended for adult patients with a difficult airway in whom anaesthesia and/or relaxation could lead to the "can not ventilate, can not intubate" situation. The paper describes three cases of elective awake intubations, as examples of our strategy in cases with a predicted difficult airway.

Case reports: Three male patients with Mallampati scores 2, 3 and 3, scheduled for elective surgery, were premedicated with 7.5 mg oral midazolam and 0.5 mg iv atropine. With the patient on the operating table in the anti-Trendelenburg position, the upper airways were anaesthetized with 4 mL of topical 2% lidocaine, administered from a nebulizer via face mask. Additionally, the base of the tongue, nasal cavity and lower throat were sprayed with 10% lidocaine solution. Immediately before insertion of the bronchoscope, the patients received intravenously, 2 mg of midazolam and 0.05-0.1 µg kg-1 of fentanyl. A 5.2 mm/65 cm fibreoptic bronchoscope was inserted into the trachea and a reinforced endotracheal tube was slid down over it. Oxygen and additional doses of lidocaine were administered through the working channel of the scope.

Conclusion: The described method is safe and effective, and can be recommended for cases where there is serious doubt about the possibility of maintaining an open airway during induction of anaesthesia, or in cases where intubation has failed during previous anaesthesia. Awake intubation is rarely associated with serious episodes of desaturation and it is usually well tolerated by motivated patients.