Topicalisation of airway for awake fibre-optic intubation: Walking on thin ice

Topicalisation of the airway by various techniques has routinely been recommended for awake fibre-optic bronchoscopy in cases of difficult airway. However, topicalisation by itself can cause airway obstruction by decreasing the tone of the laryngeal muscles and causing a dynamic air inflow obstruction. Two cases of difficult airway are illustrated where anaesthetising upper airway with nebulisation with 4% lignocaine (Xylocaine™) or 2% lignocaine (Xylocaine™) jelly resulted in stridor and upper airway obstruction. This is the first reported case of airway obstruction after lignocaine (Xylocaine™) jelly. We would like to highlight that topicalisation of airway, once thought as a relatively safe technique, can cause airway collapse if not detected and anticipated at the earliest. Pre-operative spirometry and airway ultrasonography can be useful in detecting the patients at risk of developing airway obstruction. Using a nasopharyngeal airway during topicalisation can serve as a valuable device in preventing total airway obstruction in susceptible patients.