Bristol Awake Fibre-optic Recipe

As taught on Bristol AFOI course.


This is what we use to topicalise the airway for nasal awake intubation on our training course. It is based on a technique used in the Norwich AFOI course. They published data on over 1300 endoscopies using this recipe [1].


9mg/kg has been shown to be safe when applied to the mucosa using this technique [2]. No additional analgesia or sedation is necessary if you carefully apply the lidocaine as described and take your time.


1. Glycopyrrolate 3mcg/kg iv

2. 4ml of 4% lidocaine via nebuliser (50mg absorbed)

3. Xylometazoline (Otrivine) 1 puff each nostril

4. 2.5 ml of 5% lidocaine + 0.5% phynyephrine (co-phenylcaine) to turbinates of selected nostril. Don’t sniff, coat the nasal mucosa. 125mg

5. 4 puffs of 10% lidocaine (Xylocaine) via atomiser to oropharynx, aiming for glottis. 40mg

6. 1ml aliquots of 4% lidocaine via epidural catheter within endoscope channel, up to 9mg/kg total. Specifically target: turbinates; above and below vocal cords.


The dose given as standard to each patient is 215mg.


The subsequent dose of 4% spray as you go in ml is given by:


(weight X 9) – 215



We rarely require the full 9mg/kg. In clinical practice you may wish to use iv analgesia, such as remifentanil. This is conveniently given by TCI and can be a substitute for the lidocaine nebuliser. We do not recommend sedative drugs like propofol or midazolam.


Alternative vasoconstrictors are:

1. Cocaine via cotton buds – max 1.5mg/kg

2. 1ml 1:1000 adrenaline

3. Ephedrine 0.5% drops