*Sedation:*

*Special Considerations in Human Airway Management*

○ Avoid the stress of direct laryngoscopy.

○ Direct visualization of the vocal cords.

○ Maximum incidence of success.

○ Maximum safety in awake patients.

○ Definitive control of the ET position.

○ Endoscopic study before intubation.

○ Possibility of oral or nasal application.

with the patient awake to avoid unnecessary risks.

report not so high odds of success with DA patients [21].

checklist of all the supplies needed should be disposable.

○ Minimal risk of injury.

haemodynamic response.

○ Short intubation time according to training.

○ Less traumatic and less repeated intubation attempts.

○ Possibility of execution in extreme positions [31–33].

the "gold standard" in the treatment of "predicted difficult airway."

○ Allows the administration of oxygen through the suction channel.

Due to all these advantages, intubation with FBO is the cornerstone of DA management as well as its ultimate goal: suspect and identify a DA, perform intubation

Intubation with an awake patient while maintaining spontaneous breathing is

Awake fiber-optic intubation is reported to be successful in 88–100% of DA patients. Case reports using other techniques for awake intubation (blind tracheal intubation, intubation through supraglottic devices, optically guided intubation)

Awake intubation has the following advantages [28, 34]: the patient retains the ability to keep the ventilation and airway patent and the muscle tone that keeps the pharynx clean and preserved; the collaboration of the patient and helps us pass the ET with deep breathing; with good local anesthesia, it facilitates a poor

FBOs also have disadvantages [33]: necessary training, skill, patient cooperation, longer execution time, optical fibers are fragile and require rigorous precautions. The route for tracheal intubation should take into account the patient's anatomy, surgical access, and the tracheal extubation plan. In patients with limited mouth opening, the nasal approach is the only option, while in patients who had nasal surgical interventions, the oral approach should be preferred. No evidence or consensus is found among experts on the superiority of a route if both are feasible. Awake tracheal intubation (ATI) by using video-laryngoscopy has the same success rate and safety as ATI: FBO (98.3% each) [35]. Careful selection of the tracheal tube is critical to the success of any ATI technique. It is advisable to use the tracheal tube with a smaller external diameter, as it can reduce the incidence of injury [36]. A

*Oxygenation*: Desaturation (SpO2 ≤ 90%) with low-flow (< 30 l/min-1) oxygen techniques during ATI ranges between 12% and 16% [37, 38]. When using warmed and humidified high-flow nasal oxygen, desaturation plummets to 0–1.5% [39]. Administration of supplemental oxygen during ATI is highly recommended. It should

*7.3.1.1 Advantages of FBO-guided intubation*

**294**

ATI may be safe and effective even performed in the absence of sedation [42, 43]. Its use during ATI can reduce patient anxiety and discomfort and increase procedural tolerance. In certain patient populations, the risk of over-sedation is particularly hazardous, thus an independent practitioner delivering sedation is strongly recommended. Based on our experience, we can recommend the use of minimal sedation. Two drugs, remifentanil and dexmedetomidine have been associated with high levels of patient satisfaction and low risk of over-sedation and airway obstruction. Complications are reduced when using capnography.

#### *7.3.1.2 Indications and contraindications for FBO-guided intubation*


#### *7.3.1.3 Contraindications to FBO-guided intubation*

	- Hypoxemia.
	- Laryngospasm and bronchospasm.
	- Haemodynamic disorders and arrhythmias.
	- Esophageal intubation.
	- Sore throat.
	- Tissue trauma.
	- Regurgitation or vomiting. Aspiration.
	- Stridor or oedema of the glottis.
	- Esophageal perforation.
	- Gastric distension. Rupture of the stomach.
	- Bleeding, epistaxis.
	- Eye trauma.
	- Pulmonary barotrauma.
	- Arrhythmias: bradycardia due to nasal stimulation (naso-cardial reflex) or stimulation of the region of the recurrent and superior laryngeal nerve.
	- Haemodynamic disorders: hypertension or hypotension is justified by a diminished stimulus.
	- Barotrauma: in the narrow upper respiratory tract.
	- Esophageal intubation.
	- Regurgitation and vomiting.
	- Gastric distension: stomach rupture [45].
