How To: Awake Fiberoptic Intubation

Posted by Clark Venable on 11/24/2005

I found something I wrote for residents years ago that might be of interest (or at least included for completeness).


There are many ways to topicalize and secure the airway awake, but I will describe what works well for me and concede from the start that there may be ways to improve it. I don't use nerve blocks due to my concern that I will stir up bleeding in the airway in performing them.

Equipment List


  • Glycopyrrolate-draw up 0.4 mg although we usually only administer 0.2 mg to dry secretions.
  • Midazolam-get a 5 mg vial from the pharmacy. Two milligrams may not be enough to insure the patient won't remember the experience.
  • 5% Lidocaine Ointment (not jelly)

Two 10 cc non-luer (aka slip tip) lock syringes, each containing 2 cc of 4% lidocaine and 8 cc of air (the air flushes the lidocaine through the bronchoscope.


  • Adult fiberoptic bronchoscopy cart
  • LCD video camera system for bronchoscope head
  • Oxygen tubing to attach from the auxiliary oxygen supply or a cylinder to the suction port of the bronchoscope (clears secretions, prevents fogging, prevents desaturation, and generally good for the soul)
  • Size 7 endotracheal tube (the larger the tube, the greater the chance it will hang up on the vocal cords or arytenoids). Microlaryngoscopy (MLT) tubes-size 5.0 and 6.0 can be used if available to to improve the surgeons view. In the image below, the MLT tube is below the normal tube. Note that the MLT tube is longer (33 cm) and has a larger cuff.


After securing IV access and administering an appropriate amount of midazolam premedication, place approximately two centimeters of 5% lidocaine ointment on the patients' tongue, instructing them to hold it up against the roof of their mouth. The ointment will melt, covering the tongue and spilling into the pyriform sinuses before reaching the pharynx. Have them gargle the melted ointment before swallowing it. The ointment contains a significant quantity of lidocaine, and the midazolam is chosen over narcotics as a premedicant because it raises the seizure threshold.

Once this sequence has been performed twice, the patient should be ready to accept a pink intubating oral airway. After placing it, suction the airway with the Yankauer before beginning bronchoscopy. Without having the tube loaded on the bronchoscope (FOB), pass the FOB via the pink intubating airway to within view of the vocal cords but do not touch them or pass in to the trachea yet. Spray 2 cc of 4% lidocaine on the cords via the suction port on the FOB after warning the patient you are going to make them cough, then remove the bronchoscope. After the coughing subsides, suction the airway again, re-insert the FOB, and this time enter the trachea. Anesthetize the trachea by spraying 2 cc 4% lidocaine, again warning the patient you are going to make them cough, then remove the FOB.

Next, remove the adapter from the endotracheal tube and tape it to the front of your machine with pink tape (to make it easy to find), and load the appropriate endotracheal tube on to FOB. Again place the tip of the FOB in the trachea. The patient should not cough if he/she has been properly topicalized. If they do cough, it may be worth spraying more lidocaine into the trachea. Once there, advance the endotracheal tube on the FOB in to the trachea. If you meet resistance, rotate the ETT 90 degrees counter-clockwise. This allows the bevel on the endotracheal tube to ride up over the base of the glottis and into the trachea. Before removing the FOB, measure how far above the carina the tip of the ETT tube is and confirm you can see tracheal rings. Withdraw the FOB, replace the adapter, inflate the cuff, look for EtCO2 and listen for breath sounds. Then and only then should an IV induction agent be given.

My thanks to Drs. John Drummond and John Benumof for teaching me this technique.

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