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Chapter 9 - Awake Tracheal Intubation

from Section 1 - Airway Management: Background and Techniques

Published online by Cambridge University Press:  03 October 2020

By
Charlotte Vallentin Rosenstock  and
Iljaz Hodzovic
Edited by
Tim Cook  and
Michael Seltz Kristensen
Tim Cook
Affiliation:
Royal United Hospital, Bath, UK
Michael Seltz Kristensen
Affiliation:
Rigshospitalet, Copenhagen University Hospital, Denmark
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Summary

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.

Keywords

Airway managementawake tracheal intubationdifficult airwayflexible optical bronchoscope-guided intubationvideolaryngoscopic intubation
Type
Chapter
Information
Core Topics in Airway Management , pp. 80 - 86
Publisher: Cambridge University Press
Print publication year: 2020

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References

Further Reading

Ahmad, I, El-Boghdadly, K, Bhagrath, R, et al. (2020). Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia, 75(4), 509–528.Google Scholar
Alhomary, M, Ramadan, E, Curran, E, Walsh, SR. (2018). Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis. Anaesthesia, 73, 1151–1161.Google Scholar
Cook, TM, Woodall, NM, Frerk, CM; Fourth National Audit Project. (2011). Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. British Journal of Anaesthesia, 106, 617–631.CrossRefGoogle Scholar
Frerk, C, Mitchell, VS, McNarry, AF, et al. (2015). Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia, 115, 827–848.Google Scholar
Hinkelbein, J, Lamperti, M, Akeson, J, et al. (2018). European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. European Journal of Anaesthesiology, 35(1), 6–24.CrossRefGoogle ScholarPubMed
Joseph, TT, Gal, JS, DeMaria, SJ, et al. (2016). A retrospective study of success, failure, and time needed to perform awake intubation. Anesthesiology, 125, 105–114.CrossRefGoogle ScholarPubMed
Meghjee, SPL, Marshall, M, Redfern, EJ, McGivern, DV. (2001). Influence of patient posture on oxygen saturation during fibre-optic bronchoscopy. Respiratory Medicine, 95, 5–8.Google Scholar
Roth, D, Pace, NL, Lee, A, et al. (2018). Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database of Systematic Reviews, 5, CD008874.Google ScholarPubMed

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