Awake intubation

May use any of the following techniques:

• Fiberoptics (most common)
• Direct Laryngoscopy
• Video Laryngoscopy
• Blind Nasal intubation
• Tracheostomy

Indications

When masked ventilation or intubation is suspected to be difficult, such as those with complicated anatomy or cannot tolerate supine positioning. Patient must be compliant and ideally should have a low risk of vomiting.

Contraindications

Patient refusal or inability to cooperate

Drugs

It is important to maintain spontaneous breathing, provide anxiolysis, ensure adequate comfort, and minimize secretions

• Antisialagogue
  • Glycopyrrolate - typically preferred over atropine, provide 0.2 mg IV (onset 1-2 minutes)
• Local anesthetics - though may require time, adequate local anesthesia significantly increases success rate and patient compliance
  • Lidocaine - various formulations, such as topical, atomized, or nebulized to allow for numerous delivery techniques
  • Cocaine - potent topical anesthetic and vasoconstrictor, useful in blind or awake nasal intubations
  • Cetacaine - topical combination anesthetic, useful to provide adjunct anesthesia to the mucosal surfaces of nares or posterior pharynx
• Sedation/anxiolysis - must be mild to avoid respiratory depression or apnea. Sedation is frequently required for patient tolerance
  • Midazolam - used in small boluses, but has no analgesic properties (may use fentanyl in addition)
  • Propofol - challenging to balance sedation
  • Dexmedetomidine
  • Remifentanil - rapid offset of action
  • Ketamine - titrate to effect with 10-20mg doses
• Consider ondansetron 4mg IV to blunt gag reflex

Example of Technique

• Preoxygenate the patient
• Position the patient
• Switch oxygenation from face mask to nasal cannula
• Topical anesthesia
  • May be done via transtracheal route, allowing for possible Seldinger cricothyroidotomy, if necessary as a back-up.
  • 5cc of 4% lidocaine nebulized at 5L/min
  • viscous lidocaine in back of throat
  • mucosal atomizer device or EZ atomizer of 3-4% lidocaine
• Light Sedation
• Visualization of anatomy
• Intubate
• Confirm Placement
• Secure Endotracheal Tube
• Sedation/analgesia for patient

See Also

Airway Pages

• Pre-intubation
  • Predicting the difficult airway
  • Bag valve mask ventilation
    • Oropharyngeal airway
    • Supraglottic airway
  • Apneic oxygenation
    • EBQ:ED Preoxygenation
• Induction
  • Critical care quick reference
  • Rapid sequence intubation
  • Delayed sequence intubation
• Intubation
  • Intubation (peds)
  • Direct laryngoscopy
  • Video Laryngoscopy
  • Bougie
  • The difficult airway
  • Advanced airway adjuncts
    • Supraglottic airway
  • Non-traditional intubation
    • Awake intubation
    • Nasal intubation
    • Blind digital intubation
• Surgical airways
  • Surgical cricothyrotomy
  • Needle cricothyrotomy
  • Pediatric jet ventilation
• Post-intubation
  • Mechanical ventilation (main)
  • Deterioration after intubation (DOPE)

Mechanical Ventilation Pages

• Noninvasive ventilation
• Intubation
  • Intubation (peds)
• Mechanical ventilation (main)
  • Ventilation modes
  • Initial mechanical ventilation settings
    • Initial mechanical ventilation settings (peds)
  • Adjusting mechanical ventilation settings
    • Deterioration after intubation
    • Lung recruitment maneuver
    • Ventilator high pressures
    • Ventilator associated lung injury
  • Weaning mechanical ventilation
    • Extubation
• Miscellaneous
  • ARDS and EBQ:ARDSnet
  • Airway pressure release ventilation
  • Ideal Body Weight Estimation

References

https://emcrit.org/emcrit/awakeintubation/