In most developed countries, it is not possible to be considered as the first choice due to the fact that either it is not available or there are not many people expert in using it. In our center, we either use the blocks to provide us the opportunity to intubate the patient or we use short acting medications combination without any muscle-relaxation to intubate. However, in cases with previous failed intubation, fibre-optic is used from the begining.

I was working on a study to compare the availability of fibre optic bronchoscopy, the expertise of the users and the education provided for the residents in the educational centers. I wanted to compare the results between two developed and developing countries. However, I gave it up as I was convinced that providing a decent questionnaire for a high-quality study was way difficult and subject to bias.

Currently we have multiple choices for difficult intubation having both videolaryngoscopes (such as glidescope and C-Mac) and optic laryngoscopes (such as Airtraq and LMA CTrach) in hand. However, in elective patients with large masses around airways, we are strongly recommended to consider awake intubation with fiberoptic. It has been emphasized that the best method is that you have tried it at least 12 times before (lowest estimate of learning curve), so the choices are different from person to person and between hospitals. Most important is development of an algorithm which fits the needs and facilities in every region.

For me, how often you use it depends very much on the criteria that you use to decide whether the patient is a candidate for awake intubation, in other words - patient selection. Fourth National Audit Project in the UK stated that awake intubation was not used when indicated in a number of cases that ended up as major disasters of airway management (ischemic brain damage, surgical airway, intensive care admission and death).

I agree that it needs to be practiced regularly so I suggest that fibreoptic scope should be used instead of Macintosh laryngoscope for intubation of any patient who is having general anaesthesia and requires tracheal tube placement for their surgery (providing patients have normal airway and are not aspiration risk).

So you would be using fibreoptic laryngoscope instead of Mac for intubation of a regular patient scheduled to have general anaesthesia and intubation. Although, acquired on anaesthetised patient, the skill acquired this way is likely to increase you confidence in using fibreoptic scope. One of the reasons why British anaesthetists don't use awake fibreoptic intubation often enough was to do with confidence in performing this procedure. This often led to more risky airway management options being undertaken with potentially serious consequences.

I believe that it is essential the patient selection performed with a careful visit anesthesia. In our center, in the case of a difficult intubation expected, we alert our task force and proceed with fibre optic bronchoscopy awake intubation.

In our center, a reference hospitalary center for pediatrics, in cases with previous failed intubation, fibre-optic is used from the begining.

Given the fact I work in pediatrics, awake fiberoptic is relatively uncommon as younger children simply won't cooperate. We use fiberoptics frequently in sedated/anesthetized patients as we see a number of difficult airways. I agree with Dr. Hodzovic that you cannot expect to be a master of a technique if you only use it for anticipated disasters. It should come as no surprise that if you are not doing fiberoptics except for truly difficult airways, there are failures.

In adults, with the modern availability of shorter acting sedatives and local anesthetics, awake fiberoptic intubation should not be routinely difficult in skilled hands.