What is the recommended approach for awake intubation?

Recommended Approach for Awake Intubation

Awake tracheal intubation must be considered in the presence of predictors of difficult airway management, with a structured approach focusing on effective topicalization, judicious sedation, continuous oxygenation, and limited intubation attempts. 1

Indications and Pre-Procedure Planning

• Consider awake tracheal intubation when there are predictors of difficult airway management
• Use a cognitive aid or checklist before and during the procedure 1
• Ensure all necessary equipment is readily available:
  • Flexible bronchoscope or videolaryngoscope
  • Topical anesthetics
  • Sedative medications
  • Oxygen delivery systems
  • Emergency airway equipment

Step-by-Step Approach

1. Oxygenation

• Provide supplemental oxygen throughout the entire procedure 1
• High-flow nasal oxygen is preferred if available 2
• Continuous oxygen administration reduces the risk of desaturation during the procedure

2. Topicalization of the Airway

• Apply topical nasal vasoconstrictor first 2
• Preferred agents:
  • Lidocaine 2-5% with phenylephrine 0.5% for nasal blocks 2
  • Maximum lidocaine dose must not exceed 9 mg/kg lean body weight 1, 2
• Application methods:
  • Mucosal atomization device for fine spray delivery 2
  • "Spray-as-you-go" technique under direct vision 2
  • Nebulization with 4 ml of 4% lidocaine via mouthpiece for oropharynx and vocal cords 2
• Allow adequate time (approximately 5 minutes) for onset of action 2
• Test adequacy of topicalization before instrumentation using a soft suction catheter 2

3. Sedation

• Cautious use of minimal sedation is beneficial but not mandatory 1
• Sedation should ideally be administered by an independent practitioner 1
• Effective sedation regimens (based on evidence):
  • Dexmedetomidine-midazolam combination: Dexmedetomidine 1 μg/kg over 10 min followed by 0.25 μg/kg/h with midazolam 0.02 mg/kg 3, 4, 5
  • Alternative: Remifentanil 0.63 μg/kg bolus followed by 0.062 μg/kg/min with midazolam 0.1 mg/kg 6
• Important caution: Sedation should never substitute for inadequate topicalization 1

4. Intubation Technique

• Limit attempts to three, with one additional attempt by a more experienced operator (3+1 rule) 1
• Confirm tracheal tube position with two-point check:
  • Visual confirmation
  • Capnography 1
• Only induce general anesthesia after confirming correct tube placement 1

Safety Considerations and Complications

• Monitor for signs of local anesthetic toxicity:
  • Lightheadedness
  • Perioral numbness
  • Tinnitus 2
• Have lipid emulsion available for local anesthetic toxicity 2
• Watch for potential complications:
  • Respiratory depression (more common with opioid-based sedation) 5
  • Hemodynamic instability
  • Inadequate topicalization leading to cough, laryngospasm, or bronchospasm 2

Common Pitfalls to Avoid

1. Inadequate topicalization - ensure complete anesthesia of the airway before proceeding
2. Excessive sedation - maintain patient cooperation and spontaneous ventilation
3. Rushing the procedure - allow adequate time for topical anesthetics to take effect
4. Proceeding without testing the adequacy of topicalization
5. Inducing general anesthesia before confirming correct tube placement

Training and Competency

• All departments should support anesthesiologists to attain competency and maintain skills in awake tracheal intubation 1
• Regular practice and simulation are essential for maintaining proficiency

Dexmedetomidine-based sedation regimens appear to offer better hemodynamic stability and less respiratory depression compared to opioid-based regimens, making them particularly valuable for difficult airway cases 3, 4, 5.