AWAKE INTUBATION ALGORITHM.
In cases of anticipated difficult intubations, the American Society of Anaesthesiologists and many European authors recommend awake intubation.
Indications for Awake Airway Management:
- History of difficult intubation
- Anticipated difficult airway
- Prominent protruding teeth
- Small mouth opening
- Narrow mandible
- Micrognathia
- Macroglossia
- Short, muscular neck
- Very long neck
- Limited neck extension
- Congenital airway anomalies
- Obesity
- Known airway pathology
- Known airway malignancy
- Upper airway obstruction
- Trauma
- Facial
- Upper airway
- Cervical spine
- Anticipated difficult mask ventilation
- Severe risk of aspiration
- Respiratory failure
- Severe hemodynamic instability
Awake intubation algorithm.
Anti-muscarinic drugs to dry airways. The agent most commonly used is glycopyrrolate (0.2 mg) or atropine 0.1 mg/kg 15 min prior to intubation.
Suctioning and drying the mouth and oropharynx with gauze.
Good topical anesthesia (with adequate time allowed) is essential for awake techniques. The oropharynx, base of tongue, and larynx are sprayed with a topical anesthetic (Lidocaine 2% - 10%), or the patient can gargle with a topical anesthetic. A lidocaine and phenylephrine mixture can be
nebulized via a facemask; lidocaine can also be sprayed onto
the vocal cords and into the tracheal lumen via the broncho-
scope as they are encountered or viewed.
Preoxygenation.
Light sedation with Midazolam (2-4 mg) or Ketamine (20 mg). The more cooperative your patient, the more you can rely on topical anesthesia. For those patients where raising heart rate or blood pressure is undesirable, benzodiazepine sedation will have a less effective but still salutary effect.
Intubate or place bougie and intubate using myorelaxants.
Relative contraindications for awake intubation
Lack of airway skills
Difficult airway with impending airway obstruction
Allergy to local anesthetic agents (rare)
Infection/contamination of the upper airway – blood, friable tumor, open abscess
Grossly distorted anatomy
Fracture base of the skull.
Patient refusal or uncooperative patient.
Difficult airway with impending airway obstruction
Allergy to local anesthetic agents (rare)
Infection/contamination of the upper airway – blood, friable tumor, open abscess
Grossly distorted anatomy
Fracture base of the skull.
Patient refusal or uncooperative patient.
