From patient context to an auditable plan.
This is a conditional chapter for an awake approach. Move through four galleries: decide whether the chapter fits, build the plan, make safety visible, then test the plan without preparing or administering medication.
A conditional chapter.
Enter when the airway plan includes an awake approach and topical anesthesia must be planned. This chapter does not turn one technique into a universal default.
Use this chapter
When a simulated awake-approach plan requires a topicalization strategy.
Return to the procedure
When the current plan does not require this branch.
The target is awake, comfortable, and cooperative.
The patient should remain able to respond, maintain a patent airway, breathe spontaneously, and tolerate the next planned step. The target is not an unresponsive patient.
Responsive
Can hear, answer, and follow the agreed coaching.
Comfortable and cooperative
Can communicate discomfort and tolerate the plan without escalating distress.
Airway patent
Maintains intrinsic airway tone without the preparation creating a new airway problem.
Breathing spontaneously
Maintains adequate spontaneous ventilation and oxygenation.
Comfort begins before the first dose.
The patient needs to know what is happening, why the awake approach matters, and how the team will help. Position, oxygen, monitoring, suction, working equipment, and rescue readiness all change the experience before local anesthetic touches the airway.
Explain
Agree on what the patient may feel, how to communicate, and when the team will pause.
Position
Choose a position the patient can tolerate and the operator can work from.
Oxygen and monitor
Begin before topicalization and continue throughout the awake plan.
Prepare for failure
Check suction, equipment, assistance, alternative airway, and rescue plans before starting.
Topicalize what the scope and tube will touch.
The route determines the targets. A useful plan follows the instrument from entry to trachea and names the regions that must tolerate contact.
01 · Nasal passage
Required only for the nasal route; bleeding prevention and mucosal anesthesia belong in the same plan.
02 · Oropharynx
Posterior tongue and pharynx must tolerate oral instrumentation and the gag-provoking portion of the path.
03 · Supraglottic larynx
The epiglottis, folds, and laryngeal inlet meet the approaching bronchoscope.
04 · Glottis and trachea
The airway below the cords must tolerate bronchoscope and tracheal-tube passage.
Build one cumulative dose budget.
Count every source. The approved local reference establishes the patient-specific ceiling; the plan records what was intended, what was delivered, and what remains uncertain.
Evidence note: the ceiling is not the target
The Difficult Airway Society recommends that topical lidocaine not exceed 9 mg/kg lean body weight. It describes this as a maximum that is rarely required. A lower local limit takes precedence, and every source and route must be included.
Choose a technique for the target in front of you.
No method is universally best. Match the delivery method to the route, anatomy, patient, available device, operator skill, and dose budget.
Directed atomization or spray
Places local anesthetic on selected mucosal targets without waiting for the bronchoscope to arrive.
Nebulization
Offers a low-contact start, but deposition and absorption can be variable.
Spray-as-you-go
Targets structures under bronchoscopic vision while the scope advances.
Route-specific preparation
Add nasal preparation when the nasal passage is part of the planned route.
Transtracheal orientation
Understand the target and the risk; performance instruction belongs in supervised advanced study.
Regional techniques
Glossopharyngeal, superior-laryngeal, transtracheal-injection, and ultrasound-guided performance remain in Deep Cuts.
Topicalize. Wait. Test. Advance.
Local anesthetic needs a target and time. Before the next more stimulating step, confirm that the patient remains responsive, maintains airway patency and spontaneous ventilation, and tolerates gentle contact with the topicalized region.
If the patient coughs, gags, withdraws, becomes distressed, or cannot tolerate the test, stop. Reassess the target, timing, and dose budget. Do not automatically deepen sedation.
Atraumatic testing · exact local tool and threshold applyDecide whether sedation solves a real problem.
Sedation should enter the plan only to solve a named problem. Awake FBI can be performed without it; if preparation and topicalization are not enough to manage anxiety or help the patient tolerate the next step, cautious minimal sedation may help. It cannot replace inadequate airway anesthesia.
No sedation
A legitimate plan when the patient is comfortable, cooperative, and able to tolerate the sequence.
Minimal sedation
An optional, problem-directed addition that preserves responsiveness, airway function, spontaneous ventilation, and cardiovascular stability.
One clinician watches the patient while another manages the airway.
When sedation is used, a dedicated clinician should administer, monitor, and titrate it whenever possible. The airway operator must be free to see the patient, the bronchoscope, and the procedural problem developing in real time.
Desired endpoint
Responsive to verbal coaching, airway patent, breathing spontaneously, and hemodynamically stable.
Visible monitoring
Oxygenation, ventilation, circulation, and sedation depth are followed from before topicalization through completion.
No sedative has won the argument.
The strongest comparative review found no regimen clearly superior for awake-intubation success. Choose from the local protocol by the patient, the problem sedation must solve, controllability, respiratory effect, hemodynamics, accumulation, and reversibility.
Dexmedetomidine
Often used for cooperative sedation; bradycardia, hypotension, and loading-related effects remain relevant.
Remifentanil
Rapidly titratable; respiratory depression, apnea, and loss of cooperation remain possible.
Midazolam and longer-acting opioids
Delayed peak, accumulation, amnesia, and combined respiratory effects require careful titration and reversal planning.
Propofol
Rapidly titratable, but guideline authors identify greater oversedation and airway-obstruction concern in this setting.
Recognize when the plan is no longer working.
An awake plan is only as safe as its stop. Loss of cooperation, airway tone, ventilation, oxygenation, hemodynamic stability, or dose certainty can turn preparation into a different emergency. Recognize the change early enough to stop before the technique consumes the rescue options.
Patient state
Distress, withdrawal, loss of response, or inability to cooperate.
Airway and breathing
Obstruction, impaired ventilation, desaturation, or loss of the spontaneous-breathing plan.
Medication and physiology
Suspected toxicity, significant hemodynamic deterioration, or excessive sedative effect.
Procedure and environment
Uncontrolled blood or secretions, uncertain cumulative dose, unavailable support, or a plan that is no longer workable.
Find the hidden error before it reaches a patient.
Audit a simulated awake-FBI plan. The hidden problem may involve the patient state, anatomical targets, cumulative dose, delivery method, optional sedation, monitoring, readiness test, stop signal, or rescue preparation.
Medication-free station: no medication is prepared, handled, drawn up, atomized, nebulized, injected, or administered.
Need a Gallery refresher?
Return to Room 01 and review the sequence before entering the Studio.
Carry the awake plan back to the procedure.
Do not leave this Gallery with a drug list. Leave with a simulated plan the team can explain: the desired patient state, airway targets, cumulative dose, chosen techniques, optional sedation, monitoring, readiness test, stop criteria, and rescue preparation.
Completion does not authorize medication administration or establish clinical competency.
When the usual assumptions stop working.
Advanced study examines invasive airway blocks, transtracheal injection, combination techniques, ultrasound guidance, dose uncertainty, and patients whose physiology, anatomy, or airway contamination changes the standard plan.
Invasive techniques
Supervised performance with explicit prerequisites and local authorization.
Special circumstances
Critical illness, obesity, pregnancy, obstructing pathology, soiled airway, limited access, and uncertain delivery.