EMCrit Podcast 18 – The Infamous Awake Intubation Video

This post marks the return of the Awake Intubation Video. If you’ve seen it, we will have a brand new post early next week. If you haven’t, well you are in for a treat:

Awake Intubation can save your butt!

It requires forethought and humility–you must be able to say to yourself, “I am not sure I will be able to successfully intubate this patient.” However, the payoff for this thought process is enormous. You can attempt an intubation on a difficult airway with very few downsides. If you get it, you look like a star, if you don’t you have not made the situation worse.

Two of my critical care resident specialists, Raghu Seethala and Xun Zhong, volunteered to intubate each other awake. The purpose of this was to let them gain experience, understand what their patients would feel during the procedure, and to prove that awake intubation can be done without complicated nerve block injections or fragile equipment, such as a bronchoscope.

Click Here to Download the Video

Look for this area in the lower right of the screen

Here is the procedure for ED Awake Intubation–EMCrit Style:

DRY THEM OUT & PRETREAT GAG(Do All)

If you can give it early 10-15 min before topicalizing, it will be most effective.

  • Glycopyrolate: 0.2 mg IVP (No central effects – does not cross BBB. You can use atropine, but more side effects are possible)
  • Suction and then pad mouth dry with gauze – you want the mouth very dry!
  • Adminster Odansetron 4mg IV to blunt the gag-reflex

TOPICALIZE (Do All)

  • 5 cc of 4% lidocaine nebulized @ 5 liters per min
  • Gargle with viscous lidocaine (4% best, 2% ok). Place a blob (~3 cc) on a tongue depressor, put it in the back of the throat and have the patient gargle and then spit
  • Spray the epiglottis, cords, and trachea with 4% lidocaine (3 cc) in a Mucosal Atomizer Device (MAD). The patient will cough during this spraying, wear eye/face protection
  • Have another syringe loaded with 4% lidocaine to spray with during the procedure

Note: the systemic and pulmonary absorption from this method is quite low. The only place to watch out is spraying the trachea. I would not spray more than 2-3 cc down the ol’ windpipe.

SEDATE (Choose one!)

  • Ketamine and propofol in the same syringe makes Ketofol. The classic mix is 50 mg of ketamine to make 5 cc and 50 mg of propofol to make 5 cc. Put these both in a 10 cc syringe and shake. Depending on the patient’s hemodynamics, I sometimes will use more ketamine (75% instead of 50%). Give 1-2 cc every minute until you have the patient relaxed, but still breathing and arousable.
  • Ketamine alone also works just fine. Start with 20 mg and give 10 mg every minute or so.
  • If you have it, Dexmedetomidine also works very well as long as your patient is not bradycardic.
  • If you have neither of these 2 mg of midazolam will do just fine.
  • Preoxygenate with NRB

  • Optimally position (ear to sternal notch) with the head tilted all the way back

  • Restrain both arms with soft restraints to prevent the “grabbies”

  • Switch to nasal cannula

  • INTUBATE with Fiberoptic laryngoscope and bougie

  • If the patient coughs or is uncomfortable after placing the bougie through the cords, push more med from the ketofol syringe.

  • Thread  the tube over the bougie with the laryngoscope still in the mouth

  • Confirm tube placement

That’s all for this week

For more info on awake ED intubation, you can view a complete lecture here

Thanks to Raghu and Xun for risking their singing careers and to Jimmy & Anita for technical support. *
The opinions on this site and in the video represent the author’s and not the opinions or policies of the Mount Sinai School of Medicine or Elmhurst Hospital Center. It is not my intention to provide specific medical advice for any individual patient. Please confirm anything on this video with your own clinical judgment and the policies and procedures of your institution. This video is for education purposes only; it does not represent a standard of care or clinical advice.

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Comments

  1. innovative. love it. how often are you doing this?

  2. David Lobel says:

    I am not sure when this is applicable in my practice for intubation, but I will use this for direct laryngoscopy for foreign body removal. Fishbone, chicken bone and other more creative options.

  3. Erin Schneider says:

    We just had a joint anesthesia EM conference in my residency on the difficult airway. Most anesthesiologists in the room did not like the awake intubation as a potential solution for, say, angioedema. The main complaint was that if you make the patient vomit, game over. Coincidentally, I just had an angioedema case last night, my approach was going to be glidescope +bougie with awake look (his tongue was swollen but not completely, and had no coughing or resp distress). Anesthesia jumped straight to a nasotracheal approach with intubating fiber optic scope, which worked, but only after several tries as the patient was awake and kept coughing violently when we approached the cords. In retrospect, an awake look would have worked, I think, better. Have you had cases of vomiting during the awake look procedure? If it happened, it would definitely make a bad situation worse.

    • Erin,

      Great to hear from you
      A properly prepped patient shouldn’t gag, and if they do vomit, they have the reflexes to not aspirate. That is the beauty of awake approach.

      Many anesthesiologists now reach for the glidescope rather than the fiberoptic bronch b/c they have a greater familiarity with the oral laryngoscopy approach. If you are savvy with a nasotracheal fiberoptic, it is very pretty. If you are not, it is a clusterf–k.

      scott

      • Rob anaesMD says:

        Just because they’re conscious doesn’t mean they have preserved airway reflexes. The reason this technique is possible is because your ablating the airway reflexes with local anaesthesia instead of anaesthesia and analgesia as we do with a normal induction. Thats why its a good idea to warn patients whose upper airway you have topicalised to avoid eating and drinking until sensation returns. There are many case reports of patients with angioedema whose tiny bit of remaining airway reflex and muscle tone which was managing to maintain patency was lost because of topicalisation.

  4. Rob anaesMD says:

    I didn’t realise coughing on passage of a bougie was a gold standard test of successful intubation. So your doing this for anticipated difficult intubation where the whole point is to secure the airway before inducing anaesthesia. If that is the case then pushing ketamine and propofol after passage of the bougie but before intubation is a bad idea, firstly there is no guarantee that the bougie is correctly placed, secondly it is not at all difficult to dislodge a bougie if it is moved inadvertently during railroading of the tube. Better to tolerate some coughing if the alternative is a fully induced apnoeic patient who after connection to your BVM/circuit turns out to have a tube in their esophagus, remains difficult to intubate and has not been preoxygenated during the preceding awake intubation attempt.

    • Rob, always great to have an anesthesiologist on the blog. In fact, you MUST Know the bougie is in place before proceeding. This is confirmed in two ways: seeing the bougie pass through the cords and/or feeling hold-up after gently advancing down the tracheal tree. It would be unacceptable to pass a tube over an unconfirmed bougie. Once the bougie is in place the question of whether to give a small bolus of sedative is predicated on what type of anesthesia you achieved at the sub-glottic level. If you did a cricothyroid membrane injection or passed the MAD beyond the cords, then the pt will just cough a bit and the cords will often be abducted. No additional sedation is usually necessary. If you haven’t done these, the patients often need more sedative. The ketamine or ketamine/propofol mix doesn’t result in apnea when we push it, the patient disassociates but is still breathing.

      Again, great to have you checking out the blog.

      • Rob anaesMD says:

        I agree that watching a tube pass through the cords should be enough but does anyone ever actually watch an ET tube go down the esophagus? and yet we still have esophageal intubation as a common complication of elective intubation. That is why waveform capnography is the gold standard for tube confirmation and I never push sedatives on an awake intubation until I see at least four good waveforms. I agree that a modest dose of ketofol shouldn’t render someone apnoeic usually however I have seen patients who during a titrated induction needed less than 5mls of propofol to be rendered unconscious, and lets face it the last thing you need with a patient who is known to be difficult to intubate and/or ventilate is a semiconscious possibly agitated patient. If I give my awake intubations any sedation its usually a small dose of ketamine (with 1mg of midaz to reduce dysphoria) or a low level remifentanil target controlled infusion which has the advantage of being completely cleared within less than a minute of it being ceased, although its my understanding that TCI is very uncommon in the US. (I am from Australia)
        I quite like your whole technique don’t get me wrong I would just challenge the concept of a confirmed bougie, confirming ETT position which you can ventilate through and sample CO2 return from is difficult enough. Except for a very specific few situations like a penetrating eye injury the risks of even quite aggressive coughing I feel is lower than the risk of a semiconscious can’t intubate can’t oxygenate situation. I would suggest continuing with 1-2mls at a time it was only the “push the remainder of the ketofol syringe” instruction which I felt was a little over enthusiastic.

        • Rob,

          need to be clear; really can only use visualization as confirmation with video laryngoscopy and even then we advise hold-up check. If you don’t like the push of sedatives after bougie placement then by all means make sure you either do transcricoid injection or MAD device through cords and you should have no need for that slug of sedatives. Also, remember once the bougie is in, you have confirmed that the patient is intubatable by the method you just tired, though of course I would vastly prefer not to rely on that fact at all. The continue with 1-2 ml at a time when the patient is bucking with bougie passage probably will result in more lost airways then a slug while holding the bougie in at the corner of the mouth. I respect your point though.

          • Rob anaesMD says:

            I have been thinking about it more and I still maintain visual confirmation is a very poor way to confirm tube and bougie position, I certainly would advise against it, admittedly it will likely work the majority of the time but when it fails you are talking about a major airway problem in a group of patients whose airways are difficult to maintain the calmest of circumstances. If there were a death or major morbidity due to failed intubation I just don’t think a visual confirmation or bougie hold up would be accepted as positive confirmation of correct position.
            Furthermore it occured to me that the need for significant subglottic anaesthesia or deep sedation is a non issue for one simple reason. Thousands of bronchoscopies are performed in outpatient departments around the world every day, the vast majority are done with 1-2 of midaz and a little fentanyl, the bronchoscopes are manipulated for a prolonged period of time far deeper into the bronchial tree than we are talking about with the bougie in your technique and biopsies, brushings etc are all done. This is accomplished with minimal sedation and a few squirts of topical local down the scope. In my institution anaesthetic assistance is usually only requested for higher risk procedures such as blind transbronchial biopsies and realistically we are there more to manage complications such as pneumothorax rather than provide any significant degree of sedation. Despite this simple approach the procedure is generally well tolerated, some coughing but not generally significant.

  5. Just wanted to post a note of thanks; I first saw this lecture when I was a senior resident. Loved the ideas, got to practice it 3x that spring alongside anesthesia with angioedema “urgent intubation” cases in me ED (although they preferred the fiberoptic to the glidescope, the topicalization and sedation was basically as per your video).

    A couple nights ago I got to use the technique on my own in a nasty-looking angioedema case, and it worked very well. With the proliferation of glidescopes in even small EDs, I think its a wonderful technique to have in the aresensal. Thanks for the video!

  6. Rob

    We are certainly not using visualization or bougie hold up for tube confirmation, that is what ETCO2 is for. We are using it to feel comfortable to give extra sedative if the patient is coughing after bougie placement. If you do not feel comfortable with this, as I have stated earlier, don’t do it, just give some sub-glottic lidocaine either by passing the MAD through the cords or trans-cricoid injection.

    • John Hinds says:

      Scott, an anaesthetist (anaesthesiologist) intensivist here; who used to regularly do the maxilofacial tumour and “sydrome” dental lists.

      Little tip if you’re planning on pushing sedatives on bougie passage:

      If you thread an epidural catheter down the inside of the bougie so it pops out the distal end, the proximal leur lock end will connect straight onto a co2 module.

      You can then get real time co2 trace as the bougie passes through the cords in your spontaneously breathing patient, confirming entry into the trachea.

      Can also be done down the suction port of an FO scope for the real tricky cases where the anatomy is horrendously unrecognisable – its known as a “Fibrecapnoeic” strategy.

      Hope this helps!

      -John

      • John Hinds says:

        … also, you can then use the same epidural catch to deliver a dose of local into the trachea, below the level of the cords, before passing the tube

        -John

  7. Catherine says:

    Just to clarify – you mean 50*mcg* of Fent and 50mg of Ketamine right?

  8. Great video guys, way to subject yourself to the test! I really appreciate and enjoy the dialogue. I’m glad to know we have doctors dedicated to finding innovative solutions to difficult cases.

  9. Hermann says:

    The choreographed video is misleading and bears little or no semblance to real life where an awake endotracheal intubation procedure would be needed for a patient who may be all of: highly anxious, uncooperative, with an abnormal airway anatomy, tenuous oxygenation status etc., etc.. ) In cases such as that, an awake endotracheal intubation procedure is NOT the “simple” recipe procedure as the clean-cut video describes. In particular you completely ignore the OBVIOUS need to provide supplemental oxygen and your failure to consider the use of fibre optic bronchoscope is inexcusable. Caveat emptor..

    • Hermann, This is not generally the tone we take on this particular site. If you are looking for this kind of interaction I can recommend some of the message boards such as Anesthideas.

      • Hermann says:

        Thank you. I shall no longer subscribe to your misleading site. Delete my post if you will and remove me from any and all lists.

        • What a rude and angry boy! Way to go Scott. Tried with IV scopolamine and sublingual atropine.

  10. Matt MS4 says:

    Is video laryngoscopy a necessity for this technique; can direct laryngoscopy be used if video devices are unavailable?

  11. Tracy Morton says:

    Inspired by your lecture and video, our small site (Queen Charlotte BC Canada) did a skills drill on awake intubation, led by our resident, Spencer Cleave. He posted his own video (http://vimeo.com/71509697). As the vict-, er patient, I can say that the Glidescope (or in our case, the AirTraq) was MUCH better tolerated than direct laryngoscopy. There is too much submucosal tissue that you cannot anesthetize with topicals, and the jaw lift with a bladed laryngoscope really hurts.

    Keep up the good work. Helps us bring uptown care to our (very) small town.

  12. Dear Dr. Scot Weingart
    I saw the video of the 2 residents intubating each other and I would like to make some comments about the technique employed:
    The very need for you to make this video shows that there is no ONE method, or THE method for awake intubation! If you read some reviews, there will be several answers for the question of how to intubate a awake patient. I believe that that there is NO only one correct answer to the challenge of sedating a patient for awake fiberoptic (or conventional or bougie assisted) intubation providing comfort and, without the risk of compromising either the respiration or airway. Whenever there are several solutions for a problem it means that none of the solutions are perfect, if there were a perfect one nobody would seek for other one. That is why some anesthesiologists (like me) prefer midazolam 50 to 100 mcg/Kg + fentanil 1 to 2 mcg/Kg (with or without dex) , and others prefer remifentanil. When I use dex (I have dex in one hospital and do not in the other) I do use a bolus (15 minute of 1 mcg/Kg + 0,5 mcg/kg/hour). You pointed out that you prefer “ketafol”, and there is a rationale for that: maintenance of respiration, bronchodilation (cetamine), hipnosis (proofol); attenuation of the side effects of each other betwen “keta and fol”… It is one among wise choices…
    I would like to point out some features I think that are very important. 1 – I believe that all patients in whom the clinical examination show signs of difficult mask ventilation and/or intubation should be intubated with any technique that do NOT take their capacity to either breath AND maintain their airway. You pointed it out properly in your video.I believe that the strategy of the intubation is more important than the tactic! 2 – fiberoptic intubation in the difficult intubation patient is only safer than the routine general anesthesia if the spontaneous breathing and maintenance of airway is kept by the patient. If you induce general anesthesia and paralysis both techniques (conventional laryngoscopy and fiberoptic) are hazardous. 3 – Regarding patient safety, as long as he (or she) is breathing by his(her) self, there is little difference if the intubation is proceeded via a fibroscope or via a video or conventional laryngoscope. The only difference between the video and the conventional laryngoscope will be that the rate of success will be much higher for the video device. But with exception of very abnormal airways, the fiberoptic option will not achieve better results than the videolaryngoscopic option (consider that videolaryngoscopy is quicker). 4 – In your video just local anesthesiaa (topicalization) was employed, with NO sedation. This does not reflect the average clinical scenario, and I strongly advocate the need for topicalization
    Sedation technique with continuous remifentanil is one among several well known and recommended by literature, there are others (midazolam/fentanil; midazolam/remifentanil; dexmedetomidine) the most important consideration is that, whatsoever combination of sedatives/analgesics employed, is that the ability of the patient to breath spontaneously, even with some degree of respiratory depression, should be kept. Remifentanil has the potential advantage of a very short latency and duration of effect, making the titration to a desiderate effect easier. In spite of the fact that the remifentanil infusion technique is well accepted by literature, I am more used with the midazolam/fentanil with or without dexmedetomidine (maybe because I learned that way). 4 – Administration of oxygen during the procedure is of paramount importance and should never be omitted!
    I would like to have your opinion, based in your experience, about some topics:
    1 – I usually ask the patiens who will receive a awake intubation to gargle 5 ml of 2% lidocaine for some seconds, then spit it out. After that I administer 10 % lidocaine spray to the palatoglossal arches (attempting to block the glossopharyngeal (9th), and after that I try to put a piece of gauze (embedded in 10 % lido) in the pyriform fossa bilaterally (attempting to block superior laryngeal nerve), then I put about 5 ml of 2% lidocaine gel in the back of the tongue and ask the patient to hold the gauzes and the viscous gel in the mouth as long as he(or she) can or for 5 minutes, the next step is to remove the gauzes and introduce the oral airway (in case of fiberoptic) or the blade of the laryngoscope (in case of conventional intubation). I would like your comments about mine regional anesthesia/analgesia and the one employed by your team in the awake intubation scenario. Is the cricothyreoid membrane puncture really necessary??? (I will apply lido 2% via fibroscope over the cords and bellow the cords).
    I do not have the Mucosal Atomizer Device (MAD) that you showed in the video. I have only 10% lido spray (10 mg each puff)
    Consider that I have the VAMA Madrid (resembles the Wilson) oral airway canula that instead of displace anteriorly the tongue, it displaces the soft palate backwards.
    When the oral canula is well tolerated it means (for me) that the local anesthesia of the moth and base of the tongue is OK, if not well tolerated it is a sign that I should proceed with more oral anesthesia before trying to start the fibroscopy!
    2 – What, in your opinion, would be the best ( safer and most effective) combination of epinephrine and lidocaine for both anesthesia AND vasoconstriction of the nasal mucosa for nasal fiberoptic intubation? I have neither phenylphrine, nor cocaine; and I am currently employing the commercial 2% lido with 5 mcg/ml (1:200000) adrenaline. I fill a 10 ml syringe with this solution and flush the nostrils of the patient and ask him (or her) to gargle and to spit it. as the solution reach the mouth. After that I apply some drop of Afrin and give 2 “puffs” of 10% lido spray in the chosen nostril. Even with this preparation the insertion of the tube from the nostril to the choana is the most unpleasant part of the procedure, much more discomfort reported by the patients than the intubation of the trachea itself!
    3 – Regarding the use of the bougie. I STRONGLY recommend NOT to give any more sedative to the coughing patient just because the bougie is in the trachea! The fact of having the bougie in the trachea has NOTHING TO DO WITH REAL INTUBATION. The tube may (and it happens every case in 2 (according to some literature), get trapped in the rigth arytenoid cartilage or in the tissue between the aritenoids and you cannot ventilate through the bougie, only trough the tube. Besides that, you choose awake intubation for a reason: not to take the patient’s own ability to breath and keep his airway while you are not sure that you can replace this function for him. Why would you take this safety features after making all the maneuvers to put a bougie in the trachea? If you are to give 5 ml of ketafol while you have only a bougie in the trachea, you’d have better induce a full anesthesia in the first hand! After the tube is railroaded to the trachea employing the bougie as a guide, it is safe and wise to induce general anesthesia.
    Being an anesthesiologist with some practice in fibroscopy intubation (18 months – 150 intubations – 99% via mouth, 1 % via nose) , and extensive experience in conventional laryngoscopy (26 YEARS) I do believe that fiberoscopy is NOT to be made in the difficult cases by an anesthesiologist NOT skilled in the technique, nor in the emergency scenario.
    Contrary to the common belief of most non anesthesiologists, I believe that fibroscopy is NOT the answer for difficult airway in the hipoxic, hipoventilation scenario! I think that fibroscopy takes time and is not suitable for emergencies in wich the patient is not breathing. In the emergency scenario I prefer the videolaryngoscope (with the tube bend with an stylet) that is more reliable and provides the assistant the same vision of the intubating anesthesiologist, a fact that improve the success rate of intubation.
    It is safer that the anesthesiologist try conventional laryngoscopy in the difficult case until he (or she) get experience with the fibroscope, I mean experience in several REAL patients (easy ones) not in manikins. I think the best way to master the fibroscope is to make conventional induction with paralysis in patients easy to intubate via conventional way, and try to intubate with the fibroscope, always using an oral airway, in spite of the fact that the endoscopist who first teached me the technique uses no airway at all, only a bite blocker.
    Thank you for your atention
    Marcelo S Ramos
    University of São Paulo
    Anesthesiologist
    São Paulo – Brazil

    • Marcelo,

      I agree with all you have written and if it was not clear, the reason no sedation was used in the video was b/c they were healthy volunteers. We almost always used sedation and pain control in real scenarios.

      As to the best mix for nasal, I personally would use 9 ml of 4% mixed with 1 ml of cardiac epi (1:10,000) to yield 4% with 1:100,000 epi.

      As to pushing additional “sedative,” after bougie, if I did not make this clear in the video: the sedatives that would be appropriate to push in this circumstance would either be ketamine or ketofol. Either of these should maintain respiration (as long as the push is reasonable) while attenuating the repsonse. If someone was using propofol or midazolam, this would be a bad move for the reasons you allude to.

  13. Hey Scott,
    Happy New Year, I hope you’re well- just a quick, basic question: Any reason not to use plain old cetacaine spray if you don’t have a MAD for the Lido?

    • tac 57 says:

      Methemoglobinemia from the benzocaine spray. The doses required can and usually do exceed the safe dose of benzocaibe.

  14. Scott,

    I have a (comparitively) simple question:

    At approx 1:30 or so you briefly discuss flow rate for nebulized medications at a min of 5 LPM. I am curious if you have any reference or citation for that. Unrelated to your video, I am wondering if we neb our epi faster than we need to, and miss much of our target zone (the hypopharynx/epiglotis).

    Sorry for he bunny trail off topic, but that is the way my mind works. Great video and discussion!

    Steve Cole
    Idaho, USA
    Paramedic,FTO, EMS Educator

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