Awake Intubation
OVERVIEW
- 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
INDICATIONS
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
AWAKE INTUBATION WITH A DIRECT OR VIDEO LARYNGOSCOPE
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
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
VIDEOS
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
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
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]
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
2 Comments
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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.
Cheers
Chris