Awake intubation: Difference between revisions
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==May use any of the following techniques:== | ==May use any of the following techniques:== | ||
* Fiberoptics (most common) | * Fiberoptics (most common) | ||
* Direct | * [[Direct laryngoscopy]] | ||
* Video Laryngoscopy | * [[Video Laryngoscopy]] | ||
* Blind [[Nasal intubation]] | * Blind [[Nasal intubation]] | ||
* Tracheostomy | * [[Tracheostomy]] | ||
==Indications== | ==Indications== | ||
When masked ventilation or intubation is suspected to be difficult, such as those with complicated anatomy or cannot tolerate supine positioning | When masked ventilation or intubation is suspected to be [[The difficult airway|difficult]], such as those with complicated anatomy, [[angioedema]] or cannot tolerate supine positioning. Patient must be compliant and ideally should have a low risk of vomiting. | ||
==Contraindications== | ==Contraindications== | ||
Patient | Patient refusal or inability to cooperate | ||
==Drugs== | ==Drugs== | ||
It is important to maintain spontaneous breathing | 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 | * 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 | ** '''[[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 | ** '''[[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 | ** '''[[Cetacaine]]''' - topical combination anesthetic, useful to provide adjunct anesthesia to the mucosal surfaces of nares or posterior pharynx | ||
* Sedation - must be mild to avoid respiratory depression or apnea. Sedation is frequently required for patient tolerance | * 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) | ** '''[[Midazolam]]''' - used in small boluses, but has no analgesic properties (may use fentanyl in addition) | ||
** '''[[Propofol]]''' - challenging to balance sedation | ** '''[[Propofol]]''' - challenging to balance sedation | ||
** '''[[Dexmedetomidine]]''' | ** '''[[Dexmedetomidine]]''' | ||
** '''[[Remifentanil]]''' - rapid offset of action | ** '''[[Remifentanil]]''' - rapid offset of action | ||
** '''[[Ketamine]]''' - titrate to effect with 10-20mg doses | |||
*Consider [[ondansetron]] 4mg IV to blunt gag reflex<ref>https://www.sid.ir/en/journal/ViewPaper.aspx?id=225600</ref> | |||
==Example of Technique | ==Example of Technique== | ||
* Preoxygenate the patient | * Preoxygenate the patient +/- [[glycopyrrolate]] | ||
* Position the patient | * Position the patient | ||
* Switch oxygenation from face mask to nasal cannula | * Switch oxygenation from face mask to nasal cannula | ||
* Topical anesthesia | * Topical anesthesia | ||
** May be done via transtracheal route, allowing for possible Seldinger cricothyroidotomy, if necessary as a back-up. | ** 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 | * Light Sedation | ||
* Visualization of anatomy | * Visualization of anatomy | ||
| Line 35: | Line 42: | ||
* Confirm Placement | * Confirm Placement | ||
* Secure Endotracheal Tube | * Secure Endotracheal Tube | ||
* Sedation/analgesia for patient | * Sedation/analgesia for patient | ||
==See Also== | ==See Also== | ||
*[[Intubation | {{Related Difficult Airway Pages}} | ||
{{Mechanical ventilation pages}} | |||
==External Links== | |||
*[https://emcrit.org/emcrit/awakeintubation/ EMCrit - Awake Intubation] | |||
*[https://emottawablog.com/2019/10/wake-up-awake-intubation-in-the-ed/ EM Ottawa - Wake up! Awake Intubation in the ED] | |||
==References== | ==References== | ||
https://emcrit.org/emcrit/awakeintubation/ | |||
<references/> | <references/> | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category:Procedures]] | [[Category:Procedures]] | ||
[[Category:Pulmonary]] | |||
Latest revision as of 20:36, 24 April 2024
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, angioedema 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[1]
Example of Technique
- Preoxygenate the patient +/- glycopyrrolate
- 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
- Induction
- Intubation
- Surgical airways
- Post-intubation
Mechanical Ventilation Pages
- Noninvasive ventilation
- Intubation
- Mechanical ventilation (main)
- Miscellaneous