So after the awake intubation video went up on emrap tv, I got a flurry of emails telling me how cool the concept is, but questioning who this would actually be usable on.
To answer that question, we first must discuss who actually requires intubation. If you wait until the patient is apneic, then of course you can’t use awake intubation. The idea is to intubate before the patient stops breathing.
Crash-a patient who is dead or near dead
Can’t Protect Airway
Can’t Maintain Ventilation/Oxygenation
Expected decline in Clinical Status
Now some of these make sense and some not so much
Here are my reasons to intubate:
Crash-for me this is any apneic patient
Can’t Protect Airway-this one is good, a patient with pooling secretions or obtundation with vomiting buys plastic
Possible Loss of Airway-angioedema, anaphylaxis, neck trauma. These are good reasons to intubate and usually earlier is better and safer.
Oxygenation/Ventilation issues for me mean you intervene. But this doesn’t necessarily mean intubation, if the patient has a reversible problem, put them on Non-invasive instead of intubating. See the podcast.
So it all comes down to the last reason
Expected decline-this should be the reason for many ED intubations. If the patient has O2/CO2 issues and they will be getting worse, then consider intubation.
Supply/Demand Imbalance-Last reason, not discussed as often in the ED is severe metabolic acidosis or shock where the lungs are causing a huge metabolic demand in a patient without much supply.
So who can be intubated awake? Any patient except the crash airway can be intubated awake. If you think they are a difficult airway, temporize with NIV while you topically anesthetize and then do the patient awake while they keep breathing.
Who is a difficult airway, there are few good answers.
THe LEMON rule also coined by the Walls crew is probably as good as any:
Look at head and neck
see here for more
I also discuss a new possible indication for awake intubation