Technique: The Dominic Awake Fiberoptic

The Awake Fiberoptic Intubation – The DN Technique


  1. Educate patient what to expect and what they should do
  2. This education gives you understanding of any language and/or comprehension barriers
  3. D/W surgery team reason for awake fiberoptic (difficult airway, neuro, etc)


  1. Glycopyrrolate 0.2mg when patient enter room – essential to dry secretions and absorb topical local
  2. 50 fentanyl prn for corporation up to 200mcg, slowly after patient demonstrates understanding
  3. 4-5cc Xylocaine (2%) jelly swish and swallow (numbs oropharynx)
  4. 5% Xylocaine spray (in atomizer), hold nose and have patient take deep breaths, on each inspiration spray oropharynx… confirm that “Xylocaine mist” is inhaled…. continue until mist comes out mouth at the end 0f inhalation.  Repeat for 3 breaths, then pause.
    1. note: if mist comes out too soon patient is breath holding -> reeducate
    2. repeat this process 5x
    3. Tip: put nasal airway in mouth and spray thru while inhaling
  5. Optional Transtracheal Block:
    1. find cricothyroid membrane and topicalize with local
    2. fill a 5cc syringe with 5% xyolocaine, load onto a 20g needle with catheter
    3. insert needle into cricothyroid membrane aspirating continuously until you get air bubbles
    4. if blood, back off and reinsert, same goes for if you hit cartilage
    5. once air aspirated (bubbles), pull out needle (leaving catheter) and then inject 5cc
    6. Patient is expected to cough and this helps spread local (note if patient does not react strongly to this, and you had previously performed atomize technique per above, then likely adequate block!)
  6. At this point, patient is adequately anesthetized and one can proceed with the awake fiberoptic, through use of a mouthpiece of choice.

A few further notes:

  • If reason for awake fiberoptic is neurologic in nature (myelopathy), perform neuro exam with team before and after intubation
  • Versed can interfere with patient cooperation
  • Watch for local toxicity, if patient begins shaking, consider versed +/- propofol
  • watch for hematomas in transtracheal blocks
  • Consider having screen positioned for patient to watch intubation, can reduce trauma of experience.

Thoughts on awake fiberoptics? how do you do it?