Awake Intubation


  • can be performed using direct or video laryngoscopy or using a fiberoptic scope, and various methods of topicalisation/ local anaesthesia are described
  • surgical airways can also be performed awake, using local anaesthesia


In general, awake intubation should be preferred if:

  • airway does not need to be immediately secured (i.e. sufficient time for preparation)
  • significant risk of a difficult airway
  • low risk of vomiting
  • compliant patient
  • endotracheal intubation via the nasal or oral route is feasible


Based on the approach described by Scott Weingart and Reuben Strayer:

  • Glycopyrolate 0.2 mg or Atropine .01 mg/kg – glycopyrolate is preferred, ideally given 15 min prior to next step
  • Ondansetron 4mg IV (may help decrease gag reflex)
  • Suction then pad dry mouth with gauze
  • Nebulized Lignocaine at 5 L/min, ideally 4mL of 4% lidocaine but can also use 8mL of 2% lidocaine
  • Atomized Lignocaine sprayed to oropharynx especially if unable to give full dose of nebulized lidocaine (if using a De Wilbiss atomiser point nozzle downwards and activate during inhalation for 8 breaths to anesthetise the cords and trachea)
  • ‘Viscous lignocaine lollipop’: adminster 2% viscous lignocaine on a tongue depressor and instruct patient to gargle
  • Preoxygenate
  • Position
  • Gentle restraint if needed
  • Switch to nasal cannula
  • Lightly sedate with Ketamine 20 mg aliquots every 2 minutes (alternate agents may be used, such as dexmedetomidine or remifentanil)
  • Intubate awake or place bougie, then paralyze, then pass tube
  • if patient coughs on passing bougie: spray more lignocaine using atomiser and/or push ketamine 50mg IV to sedate patient (advance ETT over bougie approx 15 seconds after ketamine administered)


Awake fiberoptic intubation – topicalise with LA as you go, cannulate trachea, assess whether trachea normal with bronchoscope, intubate passed defect, may need remifentanil or ketamine for analgesia, may be limited by blood and debris

  • if able use nasal approach
  • topicalise with co-phenylcaine forte (5 sprays to each nostril while inspiring)
  • 5 sprays of 10% lignocaine to oropharynx (4% lignocaine may be all that is available)
  • consider trans-tracheal injection via cannula to crico-thyroid membrane
  • insert successive nasopharyngeal airways up to #7.0
  • insert fiberoptic scope into naso-pharnyx
  • cannulate trachea
  • advance #7.0 ETT over scope


Scott Weingart’s approach to awake intubation with a video laryngoscope:

Richard Levitan demonstrating and discussing flexible nasoendoscopy at smaccGOLD, with assistance from Georgie Harris:

Geoff Healey from GSA HEMS teaching awake fiberoptic intubation:

An edutaining demonstration of self- awake intubation with a fiberoptic bronchoscope by Michael Bailin:

References and links

Journal articles

  • EMCrit Podcast 145 — Awake Intubation from SMACC (2014)
  • Kaviani, N., & Ranjbaran, F. Evaluation of the efficacy of oral ondansetron on gag reflex in soft palate and palatine tonsil areas. Journal of Isfahan Dental School, 2011 6(6), 691–697
  • Kramer A, Müller D, Pförtner R, Mohr C, Groeben H. Fibreoptic vs videolaryngoscopic (C-MAC(®) D-BLADE) nasal awake intubation under local anaesthesia. Anaesthesia. 2015 Apr;70(4):400-6. doi: 10.1111/anae.13016. PubMed PMID: 25764403.
  • Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med. 2002 Mar-Apr;27(2):180-92. Review. PubMed PMID: 11915066. [Fulltext]

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC


  1. in the awakeVL intubation it looks like you’re using a hyperangulated blade, is that correct?

    • A standard geometry or hyperangulated VL blade can be used for awake VL.
      Choice is determined by the context and operator preference.
      I think hyperangulated VL is likely to be more comfortable for an awake patient in most circumstances.

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