• When a difficult airway is predicted, call for a secondary provider for back up, anesthesia and ENT if available and ensure difficult airway cart available.
• With adequate preparation, coaching and anesthetic, the patient will be able to protect their airway and maintain ventilatory drive during the procedure.
• Patients considered for awake intubation must be able to tolerate the procedure (i.e., low risk of vomiting and compliant with instruction, not in severe distress).
• Communicate plan and back-up plans and actions with patient and team.
• Be prepared to switch to intubation with induction +/- paralysis or surgical airway.

• Ensure difficult airway cart is available and all personnel, including a second physician are available if possible.
• PREPARE PATIENT: the patient needs to fully understand the steps of the process and be able to verify their cooperation. Counsel patient on expected experience such as transient gagging and cough, numbness to larynx, sense of breathlessness known as glottic dyspnea. Establish nonverbal signals for communication. Thumbs up or down for patient tolerance.
• PREPARE TEAM AND EQUIPMENT/MEDICATIONS
  • Perform airway assessment.
  • Obtain RT/RN assistance and surgical back-up planning and landmarking prior to the procedure.
  • Predetermine igel or LMA size and ensure suction is tested and at the bedside.
  • Prepare intubation equipment and medications (See https://emergencycarebc.ca/clinical_resource/rapid-sequence-intubation/ and Appendix 1 for list of suggested items).
• Provide ongoing high flow oxygenation via nasal cannula.
• Optional: Ativan 1 mg SL during the topicalization step to facilitate the preparation, Glycopyrrolate 0.2 mg IV (to decrease saliva production in the mouth) and Ondansetron 4 mg IV (to decrease gag reflex), 15 minutes prior to topicalization.
• Suction and then pad patient’s mouth dry with gauze.
• ANESTHETIZE AIRWAY
  • Have the patient gargle and/or place at the posterior tongue 4% viscous lidocaine and then swallow it. Repeat oropharyngeal suction.
  • A Mucosal Atomizing Device angulated posteriorly and inferiorly towards the cords is the modality of choice for direct atomization (Image: https://canadiem.org/wp-content/uploads/2015/07/7.png). This long reach atomizer connects to a 3cc syringe with 4% lidocaine.
  • If nebulization is the only option, it can be trialed in a seated position with 5 mL of 4% lidocaine at a rate of 5-8 L/min.
• Ensure the patient is in the ideal sniffing position in an upright or semi-fowlers position if possible.
• Provider will often require a stool at the head of the bed.
• If further sedation is required, Ketamine 0.3-0.5mg/kg IV (typically 20-30 mg Ketamine) over one minute (adjusted for expected metabolic rate such as prior alcohol/drug history /frailty) to sedate and maintain the airway without full dissociation.
• Perform an awake look which confirms the ability to see the cords prior to paralysis.
• If the awake look shows good ability to visualize cords, provide full Ketamine/Paralytic and proceed with intubation.
• If unsuccessful repositioning, consider igel and secondary provider or expert assistance.
• Confirm endotracheal tube placement.

Pearls

• In a predicted difficult airway, the most experienced practitioner should be performing the first attempt. After 3 failed attempts, STOP, call for help and prepare for alternative airway management techniques.
• For a failed awake intubation, LMA/igel should be attempted with temporization until expert assistance can be obtained. Paralysis should be avoided unless Front of Neck Access (surgical cricothyroidotomy) is available.
• Use Mucosal Atomization Device through the vocal cords and spray another 2-3 mL of 4% lidocaine to anesthetize the trachea if patient coughs during the procedure.

Pitfalls

• Sedate immediately post intubation as local anesthetic will wear off.
• Maximum lidocaine dose is 7 mg/kg body weight to avoid local anesthetic toxicity.
• Ketamine is known to cause hypotension in critically ill patients or those that are depleted of catecholamines. Doses greater than 1.5 mg/kg increases this risk. Have phenylephrine 100 ug at the bedside – 10 cc syringe of 100 ug/ml Phenylephrine.

1. Recommended URLs:

   • https://litfl.com/awake-intubation/
   • https://emottawablog.com/2019/10/wake-up-awake-intubation-in-the-ed/
   • https://www.aimeairway.ca/book#/28

    

   
   

2. Continuing Education Materials:

   https://emergencycarebc.ca/wp-content/uploads/2020/09/Angioedema-Case.pdf

   
   

1. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O’Sullivan EP, Patel A, Stacey M, Vaughan D. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020;75(4):509-528.

   
   

2. Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med. 2002;27(2):180-92.

   
   

3. Merelman AH, Perlmutter MC, Strayer RJ. Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine. West J Emerg Med. 2019;20(3):466-471.

   
   

4. Alhomary M, Ramadan E, Curran E, Walsh SR. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis. Anaesthesia. 2018;73(9):1151-1161.

   
   

5. Vora J, Leslie D, Stacey M. Awake tracheal intubation. BJA Educ. 2022;22(8):298-305.