What is the recommended approach for awake intubation in a patient requiring airway management?

Awake Intubation: Recommended Approach

Awake tracheal intubation must be considered whenever predictors of difficult airway management are present, as it represents the gold standard technique with high success rates and favorable safety profile. 1

Indications and Pre-Procedure Setup

Consider awake intubation when facemask ventilation, supraglottic airway placement, tracheal intubation, or front-of-neck airway access is predicted to be difficult. 1 The technique allows airway securement before inducing general anesthesia, avoiding the catastrophic risks of "cannot intubate, cannot oxygenate" scenarios in anesthetized patients. 1

Essential Pre-Procedure Steps:

• Use a cognitive aid or checklist before and during the procedure to ensure systematic preparation and reduce errors 1
• Identify and mark the cricothyroid membrane before starting, with emergency front-of-neck airway equipment immediately available 2
• Position the patient with head elevation to optimize laryngeal view and maintain airway patency 2
• Ensure the most experienced operator available performs the procedure 2

The sTOP Framework: Four Key Elements

The Difficult Airway Society recommends breaking awake intubation into four components: sedation (optional), Topicalization, Oxygenation, and Performance. 1 The lowercase "s" emphasizes that sedation is optional and should never substitute for inadequate topicalization.

1. Oxygenation Strategy

Supplemental oxygen must always be administered throughout the entire procedure. 1

• Use high-flow nasal oxygen (HFNO) at 50-60 L/min as the primary technique 2
• HFNO reduces desaturation incidence to 0-1.5% compared to 12-16% with low-flow oxygen (<30 L/min) 1
• Continue HFNO from patient arrival through completion of the procedure 1, 2

2. Airway Topicalization

Effective topicalization is absolutely essential—never proceed without establishing and testing adequate airway anesthesia. 1, 2

Lidocaine Dosing:

• The maximum total lidocaine dose must not exceed 9 mg/kg lean body weight 1, 3
• This is a maximum, not a target—lower doses are often sufficient 1
• Track cumulative dose across all routes of administration (topical, regional blocks, surgical infiltration) 1, 3

Multimodal Topicalization Technique:

• Apply 2% lidocaine gel or 10% lidocaine spray to anterior nares 3
• Nebulize 4 mL of 4% lidocaine via face mask or mouthpiece for oropharynx and vocal cord anesthesia 3
• Apply 10% lidocaine spray to oropharynx and base of tongue 2
• Perform trans-cricothyroid block with 4-5 mL of 2% lidocaine injected into the tracheal lumen 3, 2
• Consider bilateral superior laryngeal nerve blocks with 1-2 mL of 2% lidocaine each side 3
• Allow adequate time (several minutes) for topical anesthesia to take effect before proceeding 2

Critical Pitfall:

Do NOT add epinephrine (adrenaline) to nebulized lidocaine—this is not evidence-based for awake intubation and may cause unnecessary cardiovascular stimulation. 3 Nebulized epinephrine is reserved for croup and acute airway edema, not elective awake intubation. 3

3. Sedation Protocol (Optional)

Cautious use of minimal sedation can be beneficial, but should ideally be administered by an independent practitioner. 1

Critical Principles:

• Sedation must NEVER be used as a substitute for inadequate airway topicalization 1, 3
• The patient must remain responsive to verbal commands throughout 2
• Administer sedation only after adequate topicalization is established 3

Midazolam Dosing (FDA-Approved):

• Start with 1 mg IV given over at least 2 minutes for patients under 55 years without significant comorbidities 2, 4
• Maximum total dose of 5 mg 2
• For patients over 60 years or with comorbidities, initial doses as low as 1 mg may suffice 4
• Allow an additional 2 or more minutes after each dose to fully evaluate sedative effect 4
• Titrate slowly—midazolam takes approximately three times longer than diazepam to achieve peak CNS effects 4

FDA Black Box Warning Considerations:

Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. 4 When combining sedatives with opioid premedication, reduce midazolam doses accordingly. 4

4. Performance and Technique

Limit intubation attempts to three, with one additional attempt by a more experienced operator (3+1 rule). 1, 3, 2

Device Selection:

• Choose flexible bronchoscopy or videolaryngoscopy based on operator experience and clinical scenario 1
• For patients with large submandibular glands or periglottic masses, use a channeled videolaryngoscope (such as King Vision®), which provides a guided pathway and demonstrates 92% success rates 2
• Use the videolaryngoscope with which you are most familiar and trained 2

Technique Considerations:

• Adopt a "patient-screen-patient" approach—do not become fixated on the screen; observe tube passage as it enters the oral cavity 2
• Stop immediately if inadequate topicalization is suspected, apply additional topical anesthesia, and wait adequate time for effect 2

Verification and Safety Checks

Anaesthesia should only be induced after a two-point check confirms correct tracheal tube position: 1

1. Visual confirmation of tube passing through vocal cords
2. Capnography demonstrating end-tidal CO₂

This critical safety step prevents the catastrophic error of inducing anesthesia with an esophageal intubation.

Managing Unsuccessful Attempts

If unsuccessful after 3+1 attempts: 2

• Call for help immediately
• Ensure 100% oxygen is applied
• Stop and reverse any sedative drugs
• Consider awake front-of-neck airway (cricothyroidotomy or tracheostomy) if airway management is essential 1
• If front-of-neck airway is inappropriate or unsuccessful, high-risk general anesthesia with full neuromuscular blockade and videolaryngoscopy becomes the only remaining option 1

Post-Intubation Management

Patients who undergo awake intubation for predicted difficult airway are at high risk of complications at extubation and require an appropriate extubation strategy. 1, 2

• Plan extubation following Difficult Airway Society extubation guidelines 1, 2
• Consider performing laryngoscopy before extubation to assess the airway, though this may rule out but not rule in easy subsequent intubation 1
• Keep patients nil by mouth for at least 2 hours following airway topicalization, as lidocaine has a terminal elimination half-life up to 2 hours and return of laryngeal reflexes may be delayed 1

Documentation Requirements

Document the following in clinical records: 1

• Oxygenation strategy used
• Topicalization technique and total lidocaine dose
• Sedation medications and doses
• Device and tracheal tube used
• Approach (right nasal, left nasal, oral)
• Number of attempts required

Common Pitfalls to Avoid

1. Never use sedation to compensate for inadequate topicalization—this increases risk of airway obstruction and desaturation 1, 3
2. Never exceed maximum lidocaine dose of 9 mg/kg lean body weight 1, 3
3. Never add epinephrine to nebulized lidocaine for awake intubation 3
4. Never proceed without testing adequacy of topicalization 2
5. Never induce general anesthesia before confirming correct tube position with both visual confirmation and capnography 1
6. Never perform rapid IV injection of midazolam—always titrate slowly over at least 2 minutes 4