Awake intubation

May use any of the following techniques:

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 noncompliance

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
  • Consider ondansetron 4mg IV to blunt gag reflex[1]

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

Mechanical Ventilation Pages

References

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