Awake Tracheal Intubation

Awake intubation is underused and relevant whenever difficult airway is predicted. Evidence suggests that awake videolaryngoscope-guided intubation is faster with equivalent success rate, safety profile and patient acceptance compared with flexible optical bronchoscope (FOB)-guided intubation. For successful awake intubation four elements are essential: continuous oxygenation, topicalisation, equipment handling skills and sedation. Thorough preparation is vital for the success of the procedure. This includes availability of relevant personnel, appropriate equipment, chosen method of oxygen delivery, and local anaesthetic and sedative drugs. The authors’ preferred position for awake FOB-guided intubation is face-to-face, and for awake videolaryngoscope-guided intubation the deckchair head-end position. Lidocaine is the most used local anaesthetic, applied using a variety of techniques. Meticulous and dose-appropriate application of local anaesthetic is crucial for success. Procedural sedation may be used to enhance your technique following a very careful patient evaluation for the suitability of sedation. Evidence supports using dexmedetomidine or remifentanil in order to create a situation where the patient is cooperative, oriented and tranquil. If possible, one anaesthetist with the sole responsibility of administering sedation and patient monitoring should be present during the procedure. Tracheal extubation of a patient who has been intubated awake should be planned after careful overall risk assessment of the safety of the procedure.