This lecture refers to the Awake Intubation Lecture

I've been asked, who should be intubated awake. 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.

In Ron Walls' airway manual and in his class, he gives the following reasons for intubation:

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

Evaluate 3-3-2

Mallampati

Obstruction

Neck Mobility

see here for more

I also discuss a new possible indication for awake intubation

Additional New Information

More on EMCrit

• EMCrit 194 – Definitive Emergent Awake Intubation with George Kovacs(Opens in a new browser tab)
• EMCrit 247 – The Dissociated Awake Intubation with my buddy, Ketamine(Opens in a new browser tab)
• Emergency Awake Topicalized (EAT) Intubation – An Awake Intubation Update
• EMCrit 145 – Awake Intubation Lecture from SMACC

Additional Resources

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Scott Weingart, MD FCCM

Editor-in-Chief, at EMCrit.org

An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).

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