During my training, awake intubation was the standard approach for anticipated difficult airways. We often used blind nasal and fiber-optic techniques to avoid potential can’t intubate, can’t ventilate (CICV) scenarios.
Today, devices such as the GlideScope and McGrath video laryngoscope have made many borderline airways easier to manage, so awake intubation is needed less often. Even so, any difficult airway should prompt consideration of awake intubation, if only to decide whether it might be the safer option. Clinicians may hesitate to use awake. intubation for several reasons, including:
- concern for potential patient discomfort;
- lack of experience or skill with the technique;
- avoidance of surgeon irritation regarding potential case delay; and
- production pressure.
Awake intubation, even with minimal sedation, can be comfortable if you properly prepare the patient, communicate well with the patient and your team, and are gentle.
This article will discuss how to decide when to do an awake intubation. Editor’s note: This post was originally published on September 2016 and has been completely revamped and updated for accuracy and comprehensiveness.
When To Consider Awake Intubation
The decision to intubate awake requires clinical judgment. Airway assessment findings can be helpful, but they are not reliable enough to predict every difficult intubation. Some patients appear difficult but are manageable, while others appear straightforward and prove challenging. Because no assessment is perfect, always be prepared for the unexpected.
To consider awake intubation the following requirements must be fulfilled:
- Cooperative patient: The patient must be able to understand and follow commands.
- Spontaneous respiration: The patient must be able to maintain their own airway.
- Time for preparation: Awake intubation is best suited to controlled settings when immediate airway control is not needed.
- Contraindications: There are no major contraindications such as patient refusal or severe allergy to local anesthetic.
Key Clinical Indications for Awake Intubation
When deciding whether to intubate a patient awake, ask yourself several key questions.
Will The Patient Be Difficult To Ventilate?
When you induce unconsciousness and paralyze a patient, you are betting the patient’s life that you will be able to ventilate him or her if you can’t intubate. Ability to ventilate is always more important than ability intubate. Try to imagine what might get in the way of a good mask seal. Conditions that may make the patient a challenge to ventilate, especially if occurring together, include:
- BMI greater than 40: especially if the neck is short with a large neck circumference
- Full beard
- Mallampati Class 4
- Edentulous
- Sleep apnea or snoring
- Abnormal facial anatomy or trauma
Patients who are difficult to ventilate usually have more than one of these risk factors. Successful ventilation in a complicated airway depends on skill, experience, and the availability of help if difficulty arises. Be honest with yourself: if you are unsure that you will be able to ventilate the patient, strongly consider awake intubation.
Case #1
I cared for a patient like the one in the figure. He had a large rhinophyma but otherwise seemed to have a normal airway. However, his nose would not fit inside even the largest ventilation mask, so I would not be able to create a seal or ventilate him. Rather than risk a can’t intubate, can’t ventilate crisis, I performed an awake, sedated fiber-optic intubation.
Is There a History of Difficult Intubation?
Most patients will not volunteer a history of difficult intubation, so you must ask and review available records. If there was prior difficulty, learn as much as you can about the circumstances. Video laryngoscopy now makes many repeat intubations easier, but success still depends on the reason the airway was difficult in the first place.
- Does the patient have a congenital facial anomaly like Pierre Robbin?
- Have they had radical airway surgery and neck irradiation that would limit manipulation of larynx and neck angles?
- Is there an obvious abnormality predisposing to difficult intubation or difficult ventilation?
- Can the patient open their mouth widely enough to accept the laryngoscope?
- Is their thyromental distance extremely short?
- Is there a large tumor or swelling filling their mouth or submandibular space?
If so, consider awake intubation.
Is There Upper Airway Obstruction?
Preexisting airway obstruction can worsen quickly. Induction and paralysis may convert a compromised airway into a CICV emergency.
Case #2
This 40-year-old man had Ludwig’s angina, a potentially life-threatening infection of the floor of the mouth, usually from a dental source. He complained of difficulty breathing. His swelling was so severe that his chin and neck were hard to distinguish. He was over 6 feet tall and weighed 240 lb (110 kg).
After light sedation and aerosolizing a lidocaine-pontocaine mixture into the tracheobronchial tree, he was ready. We avoided injected nerve blocks because of the risk of entering infected tissue. We also worked gently to avoid rupturing any abscess into the oropharynx.
The nasal fiber-optic intubation went smoothly. The patient took deep breaths on command while I pulled his tongue forward with gauze. My resident completed the intubation in less than 2 minutes.
Conditions such as Ludwig’s angina, angioedema, and airway trauma can distort the airway. They also raise the risk of complete airway obstruction after induction of anesthesia. Paralysis increases that risk by further reducing airway tone.
Will the Patient Tolerate Induction Medications?
Induction agents can cause hypotension through vasodilation in hypovolemic patients and myocardial depression in those with poor cardiac reserve or sepsis. We reduce this risk by choosing the drug and dose carefully and preparing to treat hypotension if it occurs. If standard induction may cause cardiovascular collapse, consider awake intubation.
Case # 3
A 30 year old woman with Acute Respiratory Distress Syndrome (ARDS) had been on the ventilator in the ICU for about a week when she suddenly developed extremely high ventilation pressures. A chest X-ray ruled out pneumothorax. She was intubated but we couldn’t ventilate through the endotracheal tube (ETT), nor could we pass a suction catheter. She was hypoxic, hypotensive with a pulse of 35. I sprayed her tongue and pharynx with cetacaine. Then I removed the endotracheal tube and reintubated the patient awake, describing to her what I was doing rather than sedating her in the face of bradycardia and imminent arrest. The removed ETT was filled with hardened secretions, onion-skinned around the inner surface until barely 1 mm of open channel remained. Now easy to ventilate, her SPO2 rapidly rose, as did her pulse and blood pressure. She ultimately recovered. (See: A Case of Endotracheal Tube obstruction)
In patients with severe shock or respiratory failure, awake intubation may be less stressful and more likely to preserve hemodynamic stability.
Can Your Patient Tolerate Apnea?
If a patient has severe hypoxia that does not improve with oxygen, the risk of decompensation during a prolonged intubation attempt is high. Whether the patient can safely tolerate apnea depends on the clinical situation.
Case # 4
The patient was a 35-year-old man, 6 ft 3 in and 350 lb (158 kg), with severe post obstructive pulmonary edema due to laryngospasm following extubation in the OR. His blood pressure was 180/110, pulse 120, respiratory rate 35, and oxygen saturation 80%. He was awake and alert but in extreme distress, tiring, and moving very little air despite repeated albuterol treatments. He was coughing up foam.
Because of his severe bronchospasm and body habitus, we feared ventilation after induction might fail. Cardiopulmonary collapse was likely if we could not intubate him quickly. Instead, we performed blind nasal intubation after rapid topical anesthesia of his nose and airway and bilateral glossopharyngeal nerve blocks. His inspiratory effort drew the endotracheal tube into the trachea on the first pass. After intubation, we stabilized him with PEEP, oxygen, and diuretics. He was extubated in the ICU the next morning.
If hypoxia is due to hypoventilation in respiratory failure, the airway appears easy to ventilate, and you expect manual ventilation to improve oxygenation if intubation is prolonged, then asleep intubation may be reasonable.
If hypoxia is due to severe airway obstruction, and both intubation and ventilation are likely to be difficult, avoid inducing apnea if possible. The risk of worsening hypoxia and a CICV emergency is high. Strongly consider awake intubation.
Is the Patient at Risk of Vomiting and Aspiration?
Patients with full stomachs or gastroesophageal reflux are often managed with rapid sequence induction. But if intubation may be difficult and the patient has been actively vomiting or at very high risk of aspiration, awake intubation may be safer. Consider nasogastric decompression in any case.
Is There Cervical Spine Instability?
Sometimes a patient will present with cervical spine compression symptoms from spinal stenosis, or will have an unstable cervical spine fracture. Careful awake intubation with neck stabilization and monitoring of neurologic signs may be the safest choice. You must avoid the patient coughing or bucking during the attempt.
In this case, awake intubation also has the advantage of allowing a neurologic exam after the intubation is completed to document that no injury has been sustained.
Early Patient Preparation Is Key to Awake Intubation
Awake intubation is harder in patients with an intact gag reflex and heavy secretions. Begin preparation as soon as you think it may be needed, even as a backup.
Give an antisialogogue, such as glycopyrrolate, and a nasal vasoconstrictor early, especially if fiber-optic intubation is possible. Both need time to work, and existing secretions take time to clear. If you do not need fiber-optic intubation in the end, little harm is done.
Rapport matters. Explain why awake intubation is needed, what the patient should expect, and what you need them to do. Most patients agree once they understand the safety concerns.
Adequate topical anesthesia is essential. With good local anesthesia, fiber-optic intubation, and even blind nasal intubation, may require little or no sedation.
Sedate cautiously. I cannot overstate this. Oversedation can quickly make a cooperative patient uncooperative as they lose inhibitions along with the ability to follow commands. It can increase the risk of losing the airway. Good local anesthesia is more dependable than deeper sedation. Dexmedetomidine may provide sedation without depressing ventilation or reducing the ability to follow commands.
It often pays to use awake intubation early, before blood, secretions, or edema make visualization impossible. If fiber-optic intubation is being used to rescue a failed intubation, you may not have time to prepare. Delay makes failure more likely.
Practice with fiber-optic bronchoscopy in patients with easy airways after induction of general anesthesia. Do not wait for an emergency.
Contraindications to Awake Intubation
Are there patients who should not be intubated awake? Yes there are.
Patient Refusal
A patient who is awake, alert, oriented, and capable of informed refusal may decline awake intubation after discussing the risks and alternatives. However, most initial hesitation is driven by fear. Approach patients with empathy, explain the risks clearly, and outline how you will maintain their safety and comfort; true refusal is uncommon.
Inability to Cooperate
Awake intubation requires active cooperation between the patient and clinician. If the patient cannot cooperate, the risk of injury to the patient or provider increases. Examples include most young children, many patients with developmental delay, and those who are intoxicated or combative.
Is There a Contraindication to Local Anesthetic Use?
Awake intubation is usually well tolerated when the airway is adequately topicalized, even with little or no sedation. However, local anesthetic use may be limited by allergy, a recent procedure that already used the maximum safe dose, or conditions such as seizure disorder that reduce the safe dose. If you cannot safely anesthetize the airway, the procedure may be painful and difficult, leading to loss of cooperation or patient refusal.
What Options Do I Have?
Some patients are poor candidates for awake intubation. They may still be difficult to intubate or ventilate. In those cases, consider topicalizing the airway, if feasible, and maintaining spontaneous ventilation under general anesthesia. Keeping the patient breathing adds a margin of safety.
For example, children are often anesthetized with an inhaled agent or total intravenous anesthesia with propofol, maintaining spontaneous ventilation. They are then intubated while asleep using a video laryngoscope, fiber-optic scope, or even blind nasal. A technique for maintaining inhalational anesthesia using a nasal airway in combination with either blind nasal or fiberoptic intubation is described here: Use Of A Nasal Airway To Assist Ventilation During Fiberoptic Intubation
Should This Patient Be Intubated in This Location, By You?
Sometimes the situation is urgent, time is short, and you’re the only clinician available to intubate. But often you have time to step back and ask an important question: do you have the skill, experienced help, and equipment needed to manage a difficult airway safely — especially if awake intubation may be required? Consider these examples:
- Should a patient with super morbid obesity, such as a BMI of 55 kg/m2 and a history of sleep apnea, be intubated at the surgicenter, where rescue resources and extra hands are in short supply?
- Should you transfer the ward patient with a difficult airway and in respiratory failure who needs intubation to the ICU prior to intubation?
- Should you schedule surgery on a child with a congenital facial anomaly at the local community hospital or transfer to a children’s hospital?
Deciding how to, and where to intubate a patient is a judgment call. It all comes down to your assessment of risk vs. benefit for patient safety. Consider the patient’s condition, the location of care, the equipment available, the experience you have, and the help that is present. Err on the side of safety if you have concerns. And regardless of which path you choose, always have plan B.
For my review article on approaching difficult intubation see:
10 Rules for Approaching Difficult Intubation
For additional articles on approaches to awake intubation see:
- Awake Intubation With The Glidescope
- Use Of A Nasal Airway To Assist Ventilation During Fiberoptic Intubation
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