What are the guidelines for awake tracheal intubation?

Guidelines for Awake Tracheal Intubation

Awake tracheal intubation must be considered in the presence of predictors of difficult airway management, with specific recommendations for preparation, performance, and post-procedure management to ensure patient safety. 1

Indications

• Must be considered when there are predictors of difficult airway management 1
• Represents the gold standard technique for securing a definitive airway in patients with predicted or known difficult airways 2
• Particularly important to avoid the life-threatening "can't intubate, can't ventilate" situation 3

Pre-procedure Preparation

Assessment and Planning

• Use a cognitive aid or checklist before and during the procedure 1, 4
• Ensure all necessary equipment is readily available:
  • Flexible bronchoscope or videolaryngoscope
  • Topical anesthetics
  • Sedative medications
  • Oxygen delivery systems
  • Emergency airway equipment 4

Patient Preparation

• Provide thorough psychological preparation with clear explanation of the procedure 5
• Administer antisialogogue to reduce secretions 3
• Apply appropriate topical anesthesia to the upper airway 3

Airway Topicalization

• Effective topicalization must be established and tested before proceeding 1
• Maximum lidocaine dose should not exceed 9 mg/kg lean body weight 1, 4
• For complete upper airway anesthesia, use a combination of:
  • Bilateral glossopharyngeal nerve blocks
  • Bilateral superior laryngeal nerve blocks
  • Recurrent laryngeal nerve block (transtracheal) 4
• For nasal routes, phenylephrine 0.5% combined with lidocaine is recommended to reduce epistaxis 4
• Avoid cocaine due to potential toxic cardiovascular complications 4
• Test adequacy of topicalization before airway instrumentation 4

Oxygenation

• Supplemental oxygen should always be administered during the procedure 1, 4
• Continuous oxygen supplementation is mandatory throughout the procedure 4
• Consider high-flow nasal cannula or noninvasive positive pressure ventilation support in patients with respiratory compromise 6

Sedation

• Cautious use of minimal sedation can be beneficial but not mandatory 1
• Sedation should ideally be administered by an independent practitioner 1
• Never use sedation as a substitute for inadequate airway topicalization 1
• Titrate sedative medications to achieve patient comfort without compromising airway patency 5

Performance of Awake Tracheal Intubation

• Limit the number of attempts to three, with one further attempt by a more experienced operator (3+1 rule) 1, 4
• Verify tracheal tube position with a two-point check:
  • Visual confirmation (seeing the tracheal tube pass through the vocal cords or visualization of tracheal rings)
  • Capnography to confirm correct placement 1
• Only induce anesthesia after confirming correct tracheal tube position 1

Management of Complications

• Monitor for signs of local anesthetic systemic toxicity:
  • Lightheadedness
  • Perioral numbness
  • Tinnitus 4
• Have lipid emulsion available in case of local anesthetic toxicity 4
• Watch for potential complications:
  • Respiratory depression
  • Hemodynamic instability
  • Cough, laryngospasm, or bronchospasm from inadequate topicalization 4

Post-procedure Management

• Keep patients nil by mouth for at least 2 hours following airway topicalization due to prolonged effect on laryngeal reflexes 4
• Document the technique used thoroughly for future airway management 4

Training and Competency

• All departments should support anesthesiologists to attain and maintain competency in awake tracheal intubation 1, 4
• Regular practice and simulation are essential to maintain skills 4
• Despite being considered the gold standard for difficult airway management, ATI is only used in approximately 0.2-2% of all intubations, highlighting the need for focused training 1, 2

Special Considerations

• For patients with pulmonary hypertension and right heart failure, consider awake bronchoscopic intubation supported with noninvasive positive pressure ventilation or high-flow nasal cannula to minimize hemodynamic instability 6
• Be prepared to manage systemic hypotension, which is the most frequent complication following the procedure in high-risk patients 6

By following these guidelines, clinicians can perform awake tracheal intubation safely and effectively when indicated, potentially avoiding the significant morbidity and mortality associated with difficult airway management.