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Awake fibreoptic intubation

If you have a private operation planned, it may involve an anaesthetic procedure, in this instance an awake fibreoptic intubation. You may wish to know what this involves.

The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.

What is the problem?

You need a general anaesthetic but this is not safe for some reason. Discuss the reason why it may be unsafe for you with your anaesthetist. Reasons may include:

Abnormal structures in the upper airways.
Difficulty opening your mouth, such as a broken jaw.
Swelling of any of the tissues in your mouth or throat, causing obstruction. Obstructions can also occur at the entrance to the trachea, called the larynx.

We normally pass a breathing tube into your trachea when you are under the general anaesthetic. This is so you can have your anaesthetic safely and efficiently. It allows the anaesthetist to make sure that you receive enough oxygen and anaesthetic gases during your operation. Because of the problems in your case, the anaesthetist needs to pass this tube while you are still awake.

What is the airway?

The airway includes the structures from your teeth, through your mouth, down your throat, your larynx and into your trachea. The trachea leads from the vocal cords to the left and right bronchus. The left and right bronchi then lead to the lungs.

What is an awake fibreoptic intubation?

An awake fibreoptic intubation, or AFI, is a procedure to place a breathing tube into your trachea while you are awake. This procedure is called intubation. It can be done either through your nose or mouth.

We use local anaesthetic to numb you from your lips or nose, to your trachea. We may also give you a sedative to make you feel sleepy and relaxed. When you are comfortable, with your mouth and throat numb, you will pass the breathing tube and we will gently slide it into your trachea. We do this with the help of a fibreoptic camera so that we can see down to your larynx and into your trachea. As soon as the breathing tube is safely secured you will have your general anaesthetic, in the normal way.

The aim

The aim of the awake fibreoptic intubation is to get the breathing tube into your trachea. You can then have your general anaesthetic safely. This means that you can have a general anaesthetic when it would not normally be safe to do so.

The benefits

Under some circumstances this is the safest way to start your anaesthetic. It may be that the shape of your neck, or size of your mouth, makes passing the tube difficult.

Doing an awake fibreoptic intubation allows you to be awake and so keep your natural reflexes, like coughing. This means that no vomit can get into your lungs. Once the tube is in place your lungs are protected. You can then have your general anaesthetic safely, as your ability to cough is no longer as important.

Are there any alternatives?

If the surgery is not major, or only involves the lower part of your body, then one of the following alternatives may be all right for you. These alternatives avoid a general anaesthetic:

Epidural - It may be possible to have an epidural, where the lower part of your body is numb and pain free. This involves placing a plastic tube next to the nerves in the spine, so that local anaesthetic can be injected, making the nerves stop working temporarily.
Spinal - This is a single injection around the nerves in the spine, similar to an epidural, but without putting the plastic tube in. This single injection is called a ‘spinal’. It does not last as long as an epidural.
Regional anaesthetic - Another method is to make individual nerves go numb temporarily. This could be your whole arm or leg. This makes a small region of the body numb, hence the name ‘regional anaesthetic’.
Local anaesthetic - Sometimes, if the surgery is minor, local anaesthetic injections can be used to numb just the operation area.
Hypnosis - More recently, some patients have used hypnosis to help them during an operation. Very few people can tolerate operations with hypnosis alone, but it may assist with the relief of anxiety, when used with other nerve blocking methods.

Whether any of these alternatives are suitable depends on the operation you need and its length. Sedation can be used with all of these injection methods, to help relieve anxiety. If you are to have one of these alternative procedures there is another information leaflet that will tell you more about it.

Who should have it done?

The only reason for having an awake fibreoptic intubation is that your condition makes it unsafe for you to have a general anaesthetic before the breathing tube is in place.

Who should not have it done?

If you are unwilling to have an awake fibreoptic intubation, you should not have it done if at all possible. If an epidural or other method where you can stay awake is safe and appropriate, then the procedure may not be required.

Author: Dr Sean White FRCA. Consultant in pain and anaesthesia