Awake intubation is a specialized technique used in airway management where the patient remains conscious or lightly sedated during the procedure. Typically, intubation occurs at the beginning of general anesthesia when the patient does not experience discomfort or have reflexive responses to the invasive procedure. Awake intubation, on the other hand, allows the patient to maintain their natural airway reflexes, reducing the risk of complications such as airway collapse or hypoxemia. Awake intubation is a critical skill for anesthesiologists—especially in managing difficult airways.
Awake intubation is employed in situations where airway management is challenging or poses significant risks. Common indications include difficult airways in patients with anatomical abnormalities, such as large masses, airway tumors, or severe facial trauma, where conventional methods may fail. It is also indicated in cases of airway obstruction caused by conditions like epiglottitis, laryngeal edema, or foreign body obstruction, as it allows securing the airway without worsening the obstruction. For patients with cervical spine instability due to trauma or conditions like rheumatoid arthritis, awake intubation can reduce neck movement and reduces the risk of spinal cord injury.
Individuals with severe obesity or obstructive sleep apnea present challenges due to difficult anatomy and a higher risk of airway collapse under sedation, making awake intubation a potentially safer option. Finally, patients with a history of failed airway management or complications during anesthesia are candidates for awake intubation to mitigate risks and ensure airway security 1,2.
Awake intubation can be performed orally or nasally, with flexible fiberoptic bronchoscopy being the most common technique, and involves several critical steps to ensure patient safety and comfort. Preparation begins with obtaining informed consent, explaining the procedure to address concerns, and reassuring the patient throughout, followed by assembling necessary equipment, including a fiberoptic bronchoscope, suction, oxygen delivery devices, and sedation medications, and establishing continuous monitoring of oxygen saturation, heart rate, and blood pressure. Airway topicalization minimizes discomfort, suppresses gag and cough reflexes, and is achieved using lidocaine sprays, nebulized lidocaine, or soaked swabs to anesthetize the oral and pharyngeal mucosa, with nerve blocks applied if deeper anesthesia is needed.
Light sedation is then administered, using agents such as dexmedetomidine or remifentanil, to ensure patient cooperation while maintaining airway reflexes. The fiberoptic bronchoscope is carefully inserted into the nasal or oral cavity and advanced toward the vocal cords under continuous oxygen delivery, enabling visualization of the vocal cords and tracheal rings. The endotracheal tube is then guided into the trachea, with placement confirmed via capnography and auscultation. Post-intubation care involves monitoring for discomfort, laryngospasm, or aspiration, transitioning to general anesthesia if necessary, and ensuring the airway remains secure 3–5.
Awake intubation provides enhanced airway control, reduced risk of desaturation, and better outcomes in difficult airway scenarios. However, it requires patient cooperation, skilled execution, and adequate preparation. Challenges of awake intubation include patient discomfort, potential for incomplete airway anesthesia, and the technical demands of an advanced technique 1,6.
References
1. Vora, J., Leslie, D. & Stacey, M. Awake tracheal intubation. BJA Educ 22, 298–305 (2022). DOI: 10.1016/j.bjae.2022.03.006
2. Ahmad, I. et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 75, 509–528 (2020). DOI: 10.1111/anae.14904
3. Awake tracheal intubation – UpToDate. https://www.uptodate.com/contents/awake-tracheal-intubation.
4. Ramkumar, V. Preparation of the patient and the airway for awake intubation. Indian J Anaesth 55, 442–447 (2011). DOI: 10.4103/0019-5049.89863
5. Nickson, C. Awake Intubation. Life in the Fast Lane • LITFL https://litfl.com/awake-intubation/ (2019).
6. Hyman, J. B. & Rosenblatt, W. H. Awake Intubation Techniques, and Why It Is Still an Important Skill to Master. Curr Anesthesiol Rep 12, 382–389 (2022). DOI: 10.1007/s40140-022-00529-x