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.
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Here is the procedure for ED Awake Intubation–EMCrit Style:
DRY THEM OUT (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!
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.
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Preoxygenate with NRB
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Optimally position (ear to sternal notch) with the head tilted all the way back
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Restrain both arms with soft restraints to prevent the “grabbies”
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Switch to nasal cannula
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INTUBATE with Fiberoptic laryngoscope and bougie
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If the patient coughs or is uncomfortable after placing the bougie through the cords, push the remainder of the ketofol syringe.
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Thread the tube over the bougie with the laryngoscope still in the mouth
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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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Hi, my name is Scott Weingart. 
{ 13 comments… read them below or add one }
innovative. love it. how often are you doing this?
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.
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
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.
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.
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.
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.
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!
Janders–much thanks for that story!
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.