Clinical case 067: awake intubation procrastination.

Had an interesting case this week. A middle-aged woman who had developed a slowly growing submandibular swelling over a week and was now not r esponding to intravenous ABs. US revealed an abscess in her salivary gland, no obvious stone. So I was asked to see her for pre-anesthetic assessment, with a view to draining his collection later in the day.

Basically she had a few comorbidities, but had had a GA for a gynae procedure 3 months ago with an easy, grade 1 intubation.
BUT today she had good going trismus, her mouth opening was about 1.5 cm and the swelling was firm, extending under her jaw just across the midline in he floor of the mouth. Her trachea and thyroid cartilage were palpable and not displaced.
She was reasonable calm and understanding of the situation.
So after NAP4 I am keen to consider an awake / fibre optic technique for this type of patient – though as a rural GP this is something I see very infrequently.

So here is my questions to you all.

Q1: Would you opt for an awake technique in his scenario?

Q2: if she refused, did not tolerate or you failed, what is the next best plan?

Q3: airway topicalisation – any good tricks, kit or videos to share?

Let me know, will post a summary of the comments and any resources I come across in a few days – going beaching in remote NW for a few days.




  1. Minh Le Cong says

    thanks Casey!
    my approach to the elective anticipated difficult airway, partic with poor mouth opening.

    Good airway exam including awake view of larynx under topicalisation and sedation/analgesia
    In a rural hospital, unlikely you have a FOB but that would be handy as allows nasal route for exam and intubation.
    Maybe you got a VL then..also handy for awake view and tube..couple of recent OT studies suggesting awake VL is as good as awake FOB intubation.

    More than likely in Oz in rural hospital you got only DL currently. First option, transfer to higher centre for care..very reasonable option in my view,
    Second option, awake look with optimal DL technique. If anatomy looks difficult, stop and transfer to higher one will call you chicken,
    If anatomy looks favourable, consider awake intubation under ketamine sedation and topicalisation.

    key here is to practice topicalisation and awake laryngoscopy all the time in your daily clinical work. Got a case of sore throat and hoarse voice in ED, ask to perform an awake laryngoscopy.
    Key to topicalisation is allow time, dry the airway, start withnebulised LA, then use a directed spray or atomised jet of LA, give it time to work and do this sitting up..dont try lying them down..causes pooled secretions and more intolerance of laryngoscopy. Use ELM to get good view of larynx with minimisation of distraction force on tongue by laryngoscope blade

    If you got 4% lignocaine, great use that. most hospitals dont so use 2% , just use more of it. be generous but stick to calculated maximum IV doses. to be very safe.

    Dont have a dedicated atomiser device..make one with a 20g plastic PIV cannula, 3 way tap, extension tubing and coonnected to oxygen tubing to run at 4L min. Connect your syringe of LA to the side port of the 3 way tap, run the oxygen and squirt in 1 ml aliquots to produce a pressure driven jet of atomised a spray gun. with some Macgills forceps you can hold and direct the tip of the spray cannula anywhere you want during DL.

    Your goal during awake look is to find the epiglottis and the posterior interarytenoid notch. Find them and you got a fighting chance to successfully tube ,awake or with RSI.
    aif decide to tube awake, use bougie. spray cords as much as possible..but if cant then do cricothyroid puncture with 18 g PIV cannula and 2 mls of LA, squirt in quickly to induce coughing. This spreads LA up to cords from below as well as most of trachea. If possible leave cannula in situ through CTM as backup for rescue oxygenation during intubation attempt.

    I would not just simply RSI or induce this woman and have a DL attempt. Its an elective case and should be planned carefully as much as possible by a proper airway exam.

  2. Have a good time ‘beaching’

    Good post and an interesting problem, especially in a remote centre.

    Despite previous ‘grade I’ I would be nervous with this lass, not least her limited mouth-opening – three fingers is my rule. To be honest, where I am I would ship her out.

    You mentioned AFOI. Whilst this may be a skill that FANZCAs and other specialist anaesthetists are comfy with, I think this is ‘tiger territory’ for the rural GP-anaesthetist or ‘occasional intubator’

    I asked Paul Baker (of difficult airway fame) about this a year ago – noone seems to have hard-and-fast data on how many AFOIs one needs to do to both GAIN competency as well as to MAINTAIN it. It’s probably >50 to gain competence then regular use to maintain skills

    I doubt that either you or I have that.

    Interestingly (well, to me at least), I’ve just surveyed rural GP-anaesthetists in Australia with a 2/3rds response rate, which gives a reasonable snapshot of what is happening ‘out there’

    18% of rural GP anaesthetists in Australia has ACCESS to a fibreoptic scope (flexible). Which is a lot more than I thought. But sensibly only 11% would be confident to use in both elective and emergency cases….the majority (approx 60%) said they would NOT be prepared to use it in any circumstances

    Which makes one wonder why this kit it ‘out there’ when there’s other kit that is affordable, robust and appropriate for GPAs. More of this in a later post – I will hang fire until presented my data in Freo later in October

    So, in summary

    (i) AFOI is ‘tiger territory’ – I would consider sending her elsewhere


    (ii) in Broome this may mean a transfer of thousands of kilometres. Minh outlines a reasonable route of topicalisation and the improvised topicaliser works a treat. But know your doses and practice on other cases (impacted fish bones are ideal)

    – then consider either DL or VL to intubate, making sure you spray the cords…

    Near in mind that the channelled Bullard type VLs (I use KingVision) can be hard to get through a narrow mouth.

    I would not support RSi then DL…it could go pear shaped

    One could consider popping in an LMA then fibreoptic intubation with a malleable stylet as an alternative…that is an easier technique. But her limited mouth opening and likelihood that unfasted means that I would be reluctant – plus the bulky devices like AirQ II (which I am a fan of) may be hard to insert.

    I will thunk more on this and try to post some pics of an ‘atomiser’ for AFOI and perhaps my own AFOI recipe…

    • SGA’s can be placed under mild to moderate sedation–I do it quite frequently in recognizer DA cases. Then stylet laryngoscopy through the SGA. The Air-Q is the “thinnest” profile, and permits full size regular tracheal tubes to be placed through them. Squirting the local anesthetic through the mask handles the anesthesia for the vocal cords–more on that later if you are interested.

  3. Forgot to add – there is an excellent app for iPad/iPhone called (imaginatively) “awake fibreoptic intubation”. Worth a look…

  4. Thanks fellows
    Awesome replies that really get at the heart of the problem

    We do have a FOB in Broome – but I have less than a handful of cases
    SO I phoned a friend and he has about twice as much experience – teamwork and 2 brains are better than one guessing!

  5. OK…so did you do an AFOI? And what other resources have you found out there (the ANZCA app is useful)

  6. A more traditional option would be a spontaneously ventilating gas induction, which requires no fancy equipment, except an anaestheitc machine. I would topicalise with 4%lignocaine with either a MAD (atomiser) cannula, or nebulise with an oropharyngeal airway taped to the nebuliser. Over time you can push the oropharyngeal airway right in. I don’t sedate, as I like the patient to be awake a cooperative. I might give a little midazolam for amnesia. Gas induce with sevoflurane, and then direct laryngoscopy.


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