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

Contraindications

Patient compliance or refusal

Drugs

It is important to maintain spontaneous breathing

• 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 - 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

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.
• Light Sedation
• Visualization of anatomy
• Intubate
• Confirm Placement
• Secure Endotracheal Tube
• Sedation/analgesia for patient

See Also

• Intubation