• Marie-Louise Mørkenborg and Michael Seltz Kristensen.
• Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark. ml.morkenborg@gmail.com.
• Can J Anaesth. 2022 Apr 1; 69 (4): 504-508.

PurposeAwake flexible bronchoscope-guided intubation is challenging in patients with extremely limited mouth opening (when there is inadequate space for an oropharyngeal airway), especially when nasal access is unavailable. Alternatives include awake front of neck access, which is an invasive procedure and not suitable for elective surgery. We present a novel technique to facilitate flexible bronchoscope-guided oral intubation in these patients.Clinical FeaturesTube tip in pharynx (TTIP) is a technique for establishing a patent airway if ventilation is difficult or has failed using a face mask, supraglottic airway, or endotracheal tube. The technique involves placing the tip of the endotracheal tube in the pharynx, 10-14 cm past the teeth, filling the cuff with air, closing the mouth and nose of the patient, and then initiating ventilation. The TTIP method thus combines the function of an oropharyngeal airway and a face mask akin to a supraglottic airway device, but is more flexible with regard to insertion depth and cuff inflation and demands only minimal mouth opening. We have adapted the TTIP technique for awake flexible bronchoscope-guided oral intubation and report the technique illustrated with three cases where mouth opening was so restricted that it precluded insertion of an oropharyngeal airway.ConclusionBy placing an endotracheal tube with the tip in the pharynx, TTIP can establish a conduit for awake oral flexible bronchoscope-guided intubation in patients with extremely limited mouth opening and unavailable nasal access. This technique requires equipment that is readily available and may help avoid unnecessary awake tracheostomy.© 2021. Canadian Anesthesiologists' Society.

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