From the Guidelines
For awake intubation, I strongly recommend using a combination of glycopyrronium bromide, topical anesthesia with lidocaine, and sedation with propofol or dexmedetomidine to ensure patient comfort and safety. When selecting medications for awake intubation, it is crucial to consider the patient's comfort, airway protection, and the potential risks associated with each medication.
- Antisialagogues such as glycopyrronium bromide 1 are recommended to reduce secretions, with a dose of 0.2-0.4 mg IV, administered 30-60 minutes pre-procedure.
- Topical anesthesia with lidocaine 1 is also essential, with a total dose not exceeding 9 mg/kg lean body weight, to minimize the risk of toxicity.
- For sedation, propofol 1 can be used with caution, at a target-controlled infusion (TCI) of 0.5-1 μg/ml, to avoid over-sedation and hypoventilation.
- Alternatively, dexmedetomidine 1 can be used, with a bolus dose of 0.5-1 μg/kg over 5 minutes, followed by an infusion of 0.3-0.6 μg/kg/h, to provide sedation while maintaining patient cooperation and spontaneous breathing. The goal of awake intubation is to provide a safe and comfortable experience for the patient, while minimizing the risks associated with airway management.
- It is essential to carefully titrate all sedatives to maintain spontaneous breathing and patient cooperation, and to monitor the patient's vital signs and airway status throughout the procedure.
- The use of remifentanil 1 or fentanyl 1 for analgesia should be considered, with caution, to avoid respiratory depression. By following this approach, clinicians can ensure a successful and safe awake intubation, with minimal risks and optimal patient outcomes.
From the FDA Drug Label
For induction of general anesthesia, before administration of other anesthetic agents. Individual response to the drug is variable, particularly when a narcotic premedication is not used. The dosage should be titrated to the desired effect according to the patient’s age and clinical status When midazolam is used before other intravenous agents for induction of anesthesia, the initial dose of each agent may be significantly reduced, at times to as low as 25% of the usual initial dose of the individual agents.
The medication midazolam can be used for awake intubation, but the provided text does not explicitly state this. However, it does describe the use of midazolam for induction of anesthesia and provides guidelines for titration and dosage.
- Midazolam is used for induction of general anesthesia.
- The dosage should be titrated to the desired effect according to the patient’s age and clinical status.
- Narcotic premedication is recommended, especially for maintenance of anesthesia. 2
From the Research
Medications Used for Awake Intubation
The following medications are used for awake intubation:
- Remifentanil: used as a single agent for awake fiberoptic intubation 3, with a median effective dose of 0.62 microg/kg for awake laryngoscopy and intubation 4
- Fentanyl: used in combination with midazolam for awake fiberoptic nasotracheal intubation 5, 6
- Midazolam: used in combination with fentanyl for awake fiberoptic nasotracheal intubation 5, 6, and with remifentanil for awake laryngoscopy and intubation 4
- Dexmedetomidine: used for awake fiberoptic nasotracheal intubation in patients with ankylosing spondylitis 6
- Penehyclidine hydrochloride: used for awake fiberoptic nasotracheal intubation in patients with ankylosing spondylitis 6
- Lidocaine: used for topical anesthesia in awake fiberoptic nasotracheal intubation 5, 4, 6
- Atropine: used in combination with midazolam and remifentanil for awake intubation using the LMA-CTrach 7
Combination Regimens
Combination regimens used for awake intubation include: