Fibreoptic Awake Intubation: From Elective Excellence to Emergency Lifesaver – Bridging the Gap in Critical Airway Management

To the Editor, We read with great interest the case report by Sankarlal et al. titled ‘Airway Management of Open Maxillofacial Injury’.1 The authors demonstrated excellent use of fibreoptic-guided intubation in a 15-year-old patient with severe maxillofacial trauma. Their systematic approach reinforces the critical importance of advanced airway management techniques in emergency scenarios. While flexible fibreoptic awake intubation is the ‘gold standard’ for difficult airway management in elective cases,2 its emergency application is often limited due to perceived time constraints and operator skill requirements. We share three emergency cases where fibreoptic awake intubation proved life-saving. A 36-year-old female with chronic kidney disease developed a large neck hematoma following accidental carotid artery puncture during jugular vein catheter insertion. With rapidly increasing neck swelling and acute respiratory distress, conventional laryngoscopy can fail due to distorted airway anatomy. Fibreoptic awake intubation using spray-as-you-go technique successfully secured the airway nasally after two attempts. A 52-year-old male posthemimandibulectomy and radical neck dissection developed profuse bleeding from the surgical site on the 6th postoperative day. Given intermittent intraoral bleeding with nasal passage relatively clear, continuous suction was maintained throughout. Visualisation was adequate, and fibreoptic awake intubation was successfully performed using spray-as-you-go technique in a head-low position. Head-low position was used briefly to minimise aspiration risk in bleeding cases. Continuous oxygen and monitoring prevented desaturation. A 76-year-old male with Hodgkin’s lymphoma developed radiotherapy-induced cellulitis with acute airway obstruction. During airway preparation, the patient suffered cardiac arrest. After return of spontaneous circulation, airway oedema and distorted anatomy made video or direct laryngoscopy impossible. The Ambu scope was preloaded and allowed prompt intubation on the first attempt without airway manipulation. This ensured rapid airway control postresuscitation. The patient was revived successfully. These cases, alongside Sankarlal et al.’s excellent presentation, emphasise several key points:1 Preparedness is of paramount importance. Similar to the authors’ approach of having ENT surgeon standby and a difficult airway cart ready, early notification and equipment preparation are crucial for emergency success. Technique modifications for emergencies The spray-as-you-go technique proves invaluable when time is limited for comprehensive airway blocks. Onset of topical lignocaine is within 30–60 s, improving as the procedure progresses. Incremental administration allowed progressive anaesthesia. The authors’ experience avoiding transtracheal blocks in facial trauma patients due to bleeding risk aligns with our findings. Transtracheal block to be avoided in facial trauma cases due to potential vascular injury, distorted neck anatomy and risk of coughing or bleeding worsening airway obscuration. While feasible in selected cases, it was avoided for patient safety in our scenarios. Premedication considerations Low-dose ketamine (0.25 mg/kg IV) was used to maintain comfort and spontaneous breathing without suppressing airway reflexes. Ketamine provides sedation, analgesia and preserves airway tone, ideal when airway anaesthesia is incomplete or limited by time. Low-dose ketamine provides patient comfort during fibreoptic procedures even with inadequately anaesthetised airways, without significantly increasing secretions. Operator skill and confidence: Regular practice in elective cases builds the confidence necessary for emergency applications. Our experience, combined with the authors’ work, demonstrates that fibreoptic awake intubation should not be reserved only for elective difficult airway cases.2 With proper preparation, appropriate premedication and skilled operators, it can be an effective and life-saving tool in emergency airway management scenarios.3 Although fibreoptic visualisation can be difficult in active bleeding, nasal approach with continuous suction aids visualisation sufficient for safe intubation. The key to success lies in adequate patient and equipment preparation, acquiring proficiency in fibreoptic awake intubation techniques and maintaining confidence to utilise these skills in critical situations. As Sankarlal et al. correctly emphasised, multidisciplinary preparedness and having backup surgical airway options remain essential components of emergency airway management.1 Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Author contributions Venkata Krishna Gollapalli (VKG):Contributed to case conceptualization, clinical data acquisition, coordinated the case series and initial drafting of the manuscript.Shital Abhay Dharamkhele (SAD): Conceived the core idea of the Letter to the Editor, critically revised the manuscript for important intellectual content, and served as the corresponding author. Ashish Hariram Nasre (AHN): Assisted in literature review, interpretation of clinical relevance, and manuscript editing. Mitesh Madangopal Rathi (MMR): Contributed to manuscript drafting, reference verification, and final proofreading. All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work. Disclosure of use of artificial intelligence (AI)-assistive or generative tools No Artificial intelligence–assisted tools were used for language editing and grammatical refinement. No AI tools were used for data generation, data analysis, interpretation, or formulation of clinical conclusions. The authors take full responsibility for the content of the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.