How to Do Awake Intubation

Written by Shannon Markus

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This article breaks down patient selection, setup, and special considerations to manage awake intubations, a rarely-utilized but essential technique in emergency airway management. Read on for our step-by-step guide!

Stay calm and tube on
Awake intubation can be considered in patients with expected difficult airways to prevent can’t oxygenate/can’t ventilate situations. Although rarely performed, the compelling potential benefits highlight the importance of familiarity with indications for and approach to awake intubation. We covered an approach to awake intubation with the 2022 ASA Difficult Airway Guidelines as well.

Here are the main takeaways from the article:

• Patient Selection: This is for anticipated difficult airway, mask ventilation, supraglottic device placement, or high-probability for cricothyrotomy (e.g. Ludwig’s angina, angioedema, malignancy). Patients must be cooperative, as the procedure takes at least 15 minutes even for skilled operators. If the patient is too unstable or agitated, opt for RSI or DSI with a cricothyrotomy setup.
• Setup: Key steps include preoxygenation, continuous monitoring (pulse ox, cardiac, capnography), and patient positioning. Calmly prepare the patient mentally for the procedure – this is CRITICAL!
• Materials: Gauze to dry secretions, oropharyngeal (OP) atomizer, tongue depressor, syringe, suction catheter, OP airway, intubating equipment (flexible endoscope, laryngoscopes, ETT w/ stylet).
• Medications: oxymetazoline (for nasal approach), glycopyrrolate or atropine to control secretions, topical anesthetic, and a mild sedative, as necessary.

The cornerstone of success is thorough and liberal application of topical anesthetic (usually 4% lidocaine), which is crucial for preservation of voluntary motor function of the cords and reduction of coughing and laryngospasm. Most clinicians in the paper used flexible endoscopes (78%) vs. rigid VL and achieved the highest success with the nasal approach (92% first-attempt success).
 
Awake Intubation Nasal Endoscopic Approach (simplified by me):

1. Prep patient: explain procedure, apply oxygen, position.
2. Prep equipment, meds, and backup plans.
3. T-15 min: Give IV glycopyrrolate, apply nasal oxymetazoline.
4. Have patient snort lidocaine cream for nasal anesthesia.
5. Dry mouth, apply lidocaine cream to tongue.
6. Atomize lidocaine to posterior oropharynx and cords.
7. Dilate nare with a lubricated gloved finger.
8. Nasally insert lubricated ETT.
9. Navigate endoscope through ETT to larynx (use jaw thrust or pull tongue if needed).
10. Spray lidocaine on cords/glottis via endoscope.
11. Enter trachea, advance ETT, and confirm with capnography.
12. Inflate cuff, administer sedation, secure ETT, and ventilate.

How will this change my practice? 
This helps to demystify awake intubations. I only encountered two cases during training, and, like many, I feel less confident with this procedure than I’d like. It makes a great case for the regular review and practice of awake techniques to improve future success. I also want to add that I really, truly, thoroughly enjoyed the physicians’ expressions in the stills from the instructional video (Figure 10 is a standout). Kudos to their commitment to medical education!

Source
Managing Awake Intubation. Ann Emerg Med. 2024 Oct 30:S0196-0644(24)00411-6. doi: 10.1016/j.annemergmed.2024.07.017. Epub ahead of print. PMID: 39480375