Not enough people are doing awake intubation in the ED or doing it as quickly as possible in the ICU. I have spoken about the technique many times on EMCrit. This lecture was specifically crafted for the EMCrit audience by my friend and airway guru, George Kovacs. I consider it to be the definitive discussion on emergent awake intubation.
For the equipment links, go to the Rapid Sequence Awake Post
Previous Podcasts on Awake Intubation
- The original method (I've moved away from the teachings here with the availability of better equipment)
- The Rapid Sequence Awake Intubation
Awake in Halifax, Part I – An interview with Ian Morris, Anesthesiologist
More Great Stuff from George Kovacs
- Lights Camera Action: Redirecting Videolaryngoscopy (Guest Post)
- Antifragile in EM by George Kovacs
- George's Self-Intubation
Additional New Information
More on EMCrit
EMCrit 236 – George Kovacs on EVLI Airway Incrementalization(Opens in a new browser tab)
EMCrit 299 – Bougie Masterclass with George Kovacs(Opens in a new browser tab)
Additional Resources
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Latest posts by George Kovacs (see all)
hi George and Scott- great talk…..some thoughts from the viking anaesthetist First of all thank you for inventing the term “topicalisation dyspnea” and shearing some thoughts on the etiology – I see it very often when doing awake intubations in the ENT theatre. We use lidocaine spray which gives 10 mg pr push (app. 100 mg/ml)……with the nice taste of (rotten) banana. Besides spray around the oral cavity I also deposit a fair amount of lidocaine on the posterior-lateral aspect of the tongue where the glossopharyngeal nerve enters the tongue. This quickly depresses the gag reflex. See you in Berlin,… Read more »
Great talk and really enjoyed all the details and little pearls put into such a great review on the topic. I agree that it is nice to have the term coined for topicalization dyspnea. Now that we are familiar with the term, I have a few questions. My first question is do you have any recommendations on management if this becomes problematic during your preparation? I have seen patients so alarmed by this that they start coughing to the point of even vomiting. Safe to say this makes the process more difficult. My only way of successful management so far… Read more »
can’t wait
Wonderful summary. I think I’ve had better luck than you guys with nebulized lidocaine, but your approach definitely will work. As faculty, we need to do a better job allowing and encouraging residents to do awake intubations semi-electively so that they aren’t learning on the fly when they get out in the community. I also advocate doing as many NPLs as one can, in part to have more practice driving the scope. For many there is perceived safety in RSI because it is familiar, but as the anesthesiologists say “it’s hard to kill a spontaneously breathing patient.” Jordan Schooler, MD,… Read more »
“Not enough people are doing awake intubation in the ED or doing it as quickly as possible in the ICU”
What is the rationale for this statement?
Mike Jasumback
That the NAP4 study showed it happens incredibly rarely in UK EDs. That every time I lecture on the topic to large audiences only a small percentage indicates that they have done one in the past year. That my co-attendings at multiple shops do not feel comfortable performing it. Do you feel the statement is not accurate?
Just not clear about the “not enough” part. It implies that this SHOULD be done more frequently, i.e. that it is indicated on clinical grounds. I think I agree that “not enough” people are doing it to stay proficient (I include myself in that group). Does that make sense?
Mike
I think you’d have a hard time explaining a gestalt-predicted difficult airway that wasn’t crash done with RSI if there is a bad outcome.
You are the intubation king Mike so I never would doubt your awake intubation skills
Hi Scott and all. I’m a first year in practice community EM doc up on Vancouver Island Canada. Twice now in two separate institutions while having rounds on awake intubation, Anaesthesia colleagues have brought up the risk of airway collapse due to ?relaxation of pharyngeal muscles? from topical lidocaine. I was quoted risk of up to a 30% decrease in airway diameter by one, but didn’t manage to get the reference from him and can’t seem to find it myself. Is this something anyone else out there has heard of, experienced, or can point me towards literature for?
Thanks!
have never seen it or heard from anyone who has. That being said, every awake intubation should have everything needed for RSI set up prior to starting.
For the physiologic difficult airway due to hypoxia, how do you keep the patient oxygenated during all this topicalization? It seems you would have to keep removing the O2 mask or bipap mask.
really is not an issue, since there is no apnea period. you can take off the mask to topicalize, pt desats, put the mask back on and they come back up. Losing preox is a huge issue when you are going to RSI, not for awake
Preoxygenation with Mapleson C or AMBU bag with PEEP valve. Keep on nasal cannula, turn NC up to 15L whilst you are doing topicalising. HFNO is great in hypoxic patients on ICU – I leave it on when intubating.
Gareth James
Anaesthetic Registrar
Wales, UK
Hi! I’m an advance practice EMT in rural Alaska. I found this podcast trying to figure out what we would do for awake patients in need of intubation for our standing orders update. We’re 2 hours away from the hospital and 1 hour away from a medic-meet with the closest paramedics who carry RSI drugs. Our current orders are to attempt a nasal intubation on a rapidly closing airway in an awake patient. Of course, none of us have ever done that because the incidence of airway burns and other awake airway patients is so low. What do you folks… Read more »
prob. ketamine-video laryng-bougie
Can Let4…lidocaine 4% topical that has epi..and tetracaine ..be used as part of your lollipop..to topicalize the back of the tongue?
–Torres
Great post/lecture. We see a lot of angioedema and one thing we’ve done for our awakes to enhance topicalization is to get a nasal trumpet in and squirt lidocaine (with air in the syringe) which seems to spray right down onto the cords. In the procedure as explained in the lecture, it seems once the initial topicalization of posterior oropharynx and nares is obtained with atomizer and lido ointment, the already partially introduced ETT is the used as an introducer for the endoscope. There wasn’t any mention of further topicalization one the scope is introduced (or maybe I missed it).… Read more »
so if you want to spray through the cords, the pt will cough so much that the scope can’t stay there, Inevitably you will have to find and navigate through the cords twice instead of once. in an elective case that is fine, but in the ED you may only get one chance. In most cases once the scope is through to carina, just advance tube, confirm and then heavily sedate with prop.etc. George advocates using the EZ-atomizer through the nose timed with the pt’s breaths which results in subglottal anesthesia.
Thanks. Sorry for the confusing question; I didn’t intend to imply going through the cords with the scope simply for subglottic topicalization. Once that scope is through it’s ETT time! What I meant is that given the poor topicalization we’ve had in past from lido nebs, we’d end up squirting a bunch through nasal trumpet to spray the cords, and then once scoping we’d stop above the cords and hit them with lido prior to navigating through for the intubation. But this was always a particularly precarious step because, as you said, they cough, and not only was this tough… Read more »