A 62-year-old woman with a history of ankylosing spondylitis and severe cervical kyphosis presents for emergency abdominal surgery. Preoperative imaging shows cervical fusion at C4–C5 with minimal cervical mobility. The anesthesiologist decides to perform awake fiberoptic intubation. During the procedure, the patient becomes anxious and begins coughing vigorously during scope insertion. Which of the following is the most appropriate immediate intervention to optimize intubation conditions?

Explanation

## Management of Cough and Anxiety During Awake Fiberoptic Intubation **Key Point:** Inadequate topical anesthesia and insufficient sedation are the primary causes of cough during awake FOI. The solution is to deepen anesthesia with spray-as-you-go technique and judicious sedation, not to abandon the procedure. ### Causes and Management of Intraoperative Cough | Cause | Mechanism | Management | |-------|-----------|------------| | Inadequate topical anesthesia | Cough reflex triggered by scope contact | Spray-as-you-go lidocaine 1%; superior laryngeal nerve block | | Insufficient sedation | Anxiety and patient movement | Titrated remifentanil (0.05–0.1 μg/kg/min) or dexmedetomidine | | Hypoxemia | Reflex coughing from hypoxia | Maintain FiO₂ 0.4–0.5; avoid 100% O₂ (atelectasis risk) | | Airway obstruction | Tongue falling back | Jaw thrust; consider nasal airway | ### Spray-as-You-Go Technique 1. **Advance scope under direct visualization** 2. **Identify anatomical landmarks** (epiglottis, arytenoids, vocal cords) 3. **Apply lidocaine 1% solution** through the working channel of the scope just before advancing further 4. **Wait 30–60 seconds** for topical effect before proceeding 5. **Repeat at each new anatomical level** (epiglottis → arytenoids → vocal cords → trachea) **High-Yield:** Remifentanil is the ideal sedative-analgesic for awake FOI because it has rapid onset, short duration, and preserves airway reflexes better than propofol. Doses of 0.05–0.1 μg/kg/min provide excellent cough suppression without deep sedation. **Clinical Pearl:** In patients with severe cervical pathology (ankylosing spondylitis, kyphosis), awake FOI is the safest approach because it avoids manipulation of the neck and maintains spontaneous ventilation. Cough during the procedure is expected and manageable with adequate anesthesia and light sedation. **Mnemonic: SAFE FOI** — Spray-as-you-go, Adequate topical anesthesia, Fiberscope technique, Excellent sedation, Foresee complications. **Warning:** Propofol 0.5 mg/kg will induce general anesthesia (loss of airway reflexes) in an awake patient, converting the procedure to an unplanned rapid sequence intubation in a patient with a difficult airway — a dangerous scenario. Avoid bolus propofol during awake FOI. [cite:Benumof & Hagberg Airway Management 3e Ch 12; Miller's Anesthesia 8e Ch 17]