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 compliance or refusal

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

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

Awake Intubation. British Journal of Anaesthesia https://academic.oup.com/bjaed/article/15/2/64/248570
Sanchez A, Iyer RR, Morrison DE. Preparation of the patient for awake intubation. In: Hagberg CA, editor. Benumof's Airway Management: Principles and Practice. Philadelphia: Mosby-Elsevier; 2007. pp. 255–80

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