• Awake intubation
• Main indication is known or predicted difficult airway. It's use in partial obstruction is unclear.
• Can be used in c-spine injury to reduce flexing/extension of the neck.
• CI in unco-operative patients, children are unlikely to cooperate. Bleeding disorders may also be a CI as may be upper airway tumours (risk of bleeding and laryngospasm)
• Drugs used during AFOI
• Local anaesthetics
• Lidocaine 5% with 0.5% phenylephrine for nasal anaesthesia
• Lidocaine 4 & 10% sprays for local laryngotracheal anaesthesia (4-6ml)
• Cocaine spray 4, 10 or 25% for topical anaesthesia at dose of 1.5 mg/kg
• Moffats solution
• Cocaine 4%, bicarbonate 5%, adrenaline
• Sedatives
• Generally accepted in a non-obstructed airway. It can improve compliance. IV midazolam, propofol TCI and remifentanil are all used.
• Some users advocate sole us of Remifentanil
• Antisialogogues
• Glycopyrollate 4-8 mcg/kg IM
• Anaesthetising the airway
• Nose
• Sensory branches are from the trigeminal nerve via sphenopalatine ganglion which lies under the nasal mucosa posterior to the middle turbinate. Fibres from the sphenopalatine ganglion also supply the pharynx, uvula and tonsils
• Lidocaine 4ml of 4% via atomiser
• Pharynx
• Via the glossopharyngeal nerve which exits the skull from the jugular foremen and enters the pharynx between the superior and middle constrictors. It also supplies the tonsillar region and posterior 1/3 of the tongue
• Spray directly with 10% lidocaine
• Can use submucosal infiltration behind the tonsillar pillars
• Larynx
• Sensory innervation is via the vagus. The SLN branches off in the carotid sheath and pierces the thyrohyoid membrane to give external and internal laryngeal branches which supply the vocal cords, epiglottis and arytenoids. The sensory supply below the cords comes from the RLN
• SLN block: semi recumbent position, a 24g needle is introduced caudally 1cm below and 2cm in front of the extremity of the prominent cornu of the hyoid and walked over the lower border of the hyoid to pierce the thyrohyoid membrane. 1-2 ml of 2% injected
• Cricothyroid puncture: 20g cannula used and 2-3 ml of 2% lignocaine infiltrated.
• Cough ensures RLN sensation is blocked
• Lignocaine soaked packs placed in the piriform fossa blocks the SLN