A 48-year-old woman with a history of ankylosing spondylitis and severe cervical kyphosis presents for emergency appendicectomy. Pre-operative airway assessment reveals a Mallampati score of IV, inter-incisor distance of 2 cm, and thyromental distance of 3 cm. Awake fiberoptic intubation is planned. After topicalization with 4% lidocaine and 10% phenylephrine spray, the fiberscope is passed transnasally. However, the scope becomes obstructed by secretions and blood, and visualization is lost at the level of the epiglottis. Oxygen saturation drops from 98% to 92%. What is the most appropriate immediate action?

Explanation

## Awake Fiberoptic Intubation — Troubleshooting Failed Visualization **Key Point:** Loss of visualization during awake fiberoptic intubation due to secretions/blood is a **technical problem, not a failed airway**. The solution is to withdraw, clear the airway, optimize visualization, and reattempt — NOT to abandon the technique or escalate prematurely. **High-Yield:** Awake fiberoptic intubation is the gold standard for predicted difficult airways. Common causes of failed visualization are: - Excessive secretions or blood - Inadequate topicalization - Fogging of the scope lens - Scope malposition All are **reversible** with simple troubleshooting. ### Troubleshooting Algorithm for Awake Fiberoptic ```mermaid flowchart TD A[Awake fiberoptic in progress]:::outcome --> B{Visualization lost?}:::decision B -->|Yes| C[Withdraw scope immediately]:::action C --> D[Suction pharynx, clear secretions/blood]:::action D --> E[Re-topicalize if needed]:::action E --> F[Reattempt with fresh scope or clean lens]:::action F --> G{Success?}:::decision G -->|Yes| H[Proceed with intubation]:::action G -->|No| I[Consider alternative route or technique]:::action B -->|No, adequate view| J[Advance scope and intubate]:::action ``` **Clinical Pearl:** SpO₂ 92% on supplemental oxygen during awake fiberoptic is still safe — the patient is breathing spontaneously and has an open airway. There is NO indication for emergency surgical airway at this point. **Mnemonic: STOP-SUCTION-RETRY** — When fiberoptic visualization fails: - **S**top advancing - **T**urn off scope - **O**pen airway (withdraw scope) - **P**hysical suction of pharynx - **S**uction scope lens if fogged - **U**pdate topicalization - **C**lean or change scope - **T**ry again - **I**f still fails, consider alternative - **O**nly escalate if oxygenation fails - **N**ever abandon awake technique prematurely ### Why NOT the Other Options **Blind nasal intubation:** Contraindicated in ankylosing spondylitis with severe kyphosis — the anatomy is severely distorted and blind placement risks esophageal intubation, aspiration, and airway trauma. **Inhalational induction:** This patient has a predicted VERY difficult airway (Mallampati IV, inter-incisor 2 cm, thyromental 3 cm). Inhalational induction risks loss of airway control, aspiration, and inability to intubate. Awake fiberoptic was chosen precisely to avoid this. **Cricothyrotomy:** The patient is breathing spontaneously, oxygenating adequately (SpO₂ 92%), and has an open airway. There is NO failed oxygenation scenario. Surgical airway is premature and violates the algorithm. [cite:Difficult Airway Society Guidelines 2015; Frerk et al. Br J Anaesth 2015]