Chapter 8-How to do awake tracheal intubations (oral & nasal)

General Considerations for Awake Tracheal Intubation

• Awake tracheal intubation is a crucial skill for acute-care clinicians, enabling effective airway management in circumstances where traditional intubation methods may be insufficient or dangerous. It is particularly important in cases involving complex anatomy, severe airway obstruction, or patients with high risk factors for intubation failure.

• There are three primary methods of tracheal intubation:

  • Rapid-Sequence Intubation (RSI): A widely used approach in emergency medicine, which emphasizes speed and minimizes the risk of aspiration. It is particularly effective in unresponsive or unstable patients but can result in hemodynamic instability due to rapid administration of induction agents.

  • Awake Technique: This method involves the application of topical airway anesthesia, allowing patients to maintain some level of consciousness, which can facilitate airway control and patient safety.

  • Facilitation by Deep Sedation: While this approach does not involve pharmacologic paralysis, it typically leads to a significant reduction in consciousness, making airway control more challenging.

• In certain cases, patients may necessitate a primary surgical airway (such as a tracheostomy or cricothyrotomy) when other methods are deemed insufficient or impractical.

Key Points

• If the likelihood of a difficult airway is assessed and found clinically significant, clinicians should consider utilizing an awake intubation approach, provided the patient is cooperative. Patient cooperation is key in reducing anxiety and facilitating the intubation process.

• The awake technique primarily employs upper airway anesthesia, which can be applied through various methods, such as topical sprays, gels, or nerve blocks, often complemented by mild sedation to enhance patient comfort.

• Deep sedation should not be relied upon to mitigate muscle tone or to compensate for inadequate nebulized anesthesia, as this may lead to airway compromise.

• Clinicians should ideally utilize the technique they are most experienced with for awake intubation to ensure better outcomes and minimize complications:

  • Local anesthetics can be delivered in multiple forms (ointment, jelly, or inhaled) to best suit the situation and patient needs.

  • Performing awake intubation with patients sitting or semi-sitting enhances cooperation, comfort, and overall procedural success rates.

  • Precision laryngoscopy techniques are essential in minimizing patient discomfort while inserting the laryngoscope blade, particularly in patients who may be anxious or distressed.

Advantages of Awake Tracheal Intubation

• Conscious Patient Benefits:

  • Continuous spontaneous breathing is maintained throughout the procedure, which is crucial for individuals with compromised respiratory function.

  • The method preserves a patent airway, reducing the likelihood of airway obstruction during intubation.

  • It protects against the aspiration of gastric contents, making this method safer for patients with known or suspected gastroesophageal reflux.

  • Light sedation can minimize hypotensive risks associated with the rapid administration of RSI agents, thus offering a more stable hemodynamic profile.

• Patient cooperation during the procedure is critical: some patients may exhibit passive cooperation, permitting successful awake intubation even when distressed. Candidates in the early stages of airway obstruction or those with partially obstructed airways often represent ideal candidates for awake approaches, as their airway reflexes may still be intact.

Comparison of Different Methods of Intubation (Table 8-1)

Awake Intubation

• Advantages:

  • Continuous spontaneous breathing ensures patient safety and inhibits desaturation.

  • Maintains airway integrity while avoiding the complications of hypotension that may arise from RSI drugs.

• Disadvantages:

  • The clinician's perception of potential discomfort can be a barrier to this method, leading to hesitancy in its application.

  • Requires strong patient cooperation and understanding to be effective.

  • Comprehensive training is necessary to master airway anesthesia techniques and proper laryngoscopy skills.

Deep Sedation

• Advantages:

  • It can assist with uncooperative patients, making the procedure potentially more tolerable for some.

  • It may be perceived as more humane by both patients and providers, alleviating fear and anxiety associated with awake procedures.

• Disadvantages:

  • Often results in a false sense of security, allowing undesirable reflex actions (e.g., gagging) that may complicate intubation.

  • Abolishes airway protection for full-stomach patients, increasing the risk of aspiration events.

  • This method can lead to significant hemodynamic instability, making it less suitable for high-risk patients.

  • There are no guarantees of safe intubation conditions, particularly in complex cases.

Rapid-Sequence Intubation (RSI)

• Advantages:

  • Facilitates muscle relaxation during laryngoscopy, improving visualization and access.

  • It is fundamentally not dependent on patient cooperation, making it applicable in unresponsive patients.

• Disadvantages:

  • Requires advanced training and meticulous proficiency to be applied safely.

  • The induction agents used can result in profound hypotension, necessitating close monitoring of the patient’s hemodynamic status.

Awake Tracheotomy or Cricothyrotomy

• Advantages:

  • There is a significantly reduced risk of compromising airway integrity during the procedure, maintaining both awareness and safety for the patient.

• Disadvantages:

  • It necessitates a skilled practitioner with the requisite surgical abilities and access to essential equipment, which may not always be available in emergency contexts.

When and Why to Perform an Awake Tracheal Intubation

1. Predicted Difficult Airway:

   • Indicated when there is uncertainty regarding the feasibility of standard intubation, particularly for patients with known anatomical challenges, such as mandibular hypoplasia or severe obesity.

2. Exaggerated Hypotensive Response to RSI Induction Medications:

   • Recommended for patients exhibiting significant hemodynamic instability, as awake intubation avoids the common blood pressure drops associated with RSI drugs.

3. When RSI is Unnecessary:

   • This method is ideal for critically ill patients or those with diminished levels of consciousness, provided they remain capable of respiratory function but do not require complete sedation.

Oral vs. Nasal Route

• Oral Intubation: Generally preferred by most clinicians due to familiarity, effectiveness, and a higher success rate across most patient categories.

• Nasal Intubation: Utilized when oral intubation is contraindicated or completely impossible; however, it is often associated with lower success rates and an increased risk of complications, such as epistaxis or sinusitis. Increased clinician familiarity with the nasal route may enhance its effectiveness.

Tools for Awake Tracheal Intubation

• The range of devices used for awake intubation varies widely, from traditional laryngoscopes to advanced fiber optics that can aid in visualization and anatomical differentiation during the procedure.

• Flexible fiber optics, while common in operating rooms, allow for greater maneuverability and visualization of challenging airways; however, direct laryngoscopy may be the preferred choice in emergency settings due to its speed and availability.

Topical Airway Anesthesia

• Various delivery methods for local anesthetics include ointments, jellies, or nebulized aerosols. The effectiveness and type of anesthetic may depend on patient factors and the route of intubation selected.

• Key considerations for anesthetic choice include:

  • Oropharyngeal: Necessary for adequate anesthesia typically includes targeting the glossopharyngeal nerve pathways with lidocaine, administered either through ointment or jelly form.

  • Lidocaine Application Technique:

    • Ointment: Should be applied to the back of the tongue to ensure maximum effect; onset occurs within 2-5 minutes and lasts for approximately 20 minutes.

    • Spray Techniques: Offer effective application to sensitive areas using aerosol devices to ease patient discomfort during sedation and intubation.

Sedation in Awake Intubation

• Light Sedation Goals: The primary goal is to provide comfort while ensuring the patient remains responsive and retains critical airway reflexes throughout the procedure.

• Deep Sedation Risks: This technique carries the danger of impairing the patient's respiratory drive and ultimately resulting in a loss of airway protection, potentially leading to catastrophic outcomes.

• Titration Recommendations: Begin sedation with small doses (e.g., midazolam or fentanyl) and monitor the patient's response closely, adjusting as necessary to maintain safety without sacrificing comfort.

Performing Awake Intubation Using Direct Laryngoscopy

• Ensuring that the patient is positioned correctly is vital for maximizing comfort and minimizing anxiety before the procedure begins.

• Precision Laryngoscopy: This technique is essential in protecting sensitive anatomical structures while introducing the laryngoscope to visualize the larynx securely and efficiently.

• Following established procedural steps closely allows for the visualization of the larynx and facilitates a smooth and effective intubation process.

Awake Oral Intubation Steps

1. Preoxygenate the patient with supplemental oxygen to maximize oxygen saturation before the procedure.

2. Confirm availability of all necessary equipment, including endotracheal tubes, laryngoscopes, and local anesthetics, or adjuncts.

3. Administer topical airway anesthesia using appropriate techniques.

4. Proceed with direct laryngoscopy and intubate gently while ensuring good visualization of the vocal cords.

5. Thoroughly confirm the tube's position following intubation with appropriate assessment techniques such as listening for breath sounds.

6. Provide additional analgesia and sedation as required based on patient response and comfort.

Blind Nasotracheal Intubation (BNTI)

• Due to its complicated technique and the higher risk of complications compared to other methods, BNTI is seldom used in modern practice.

• The effectiveness of this method significantly relies on proper anesthetic application and a comprehensive understanding of potential anatomical variations that may complicate the procedure.

• Clinicians must adhere to proper techniques and troubleshooting methods to ensure success and safety, particularly in patients with known spinal issues or other complicating factors.

Summary

• Overall, awake intubation stands as an essential component of emergency care, demanding particular knowledge and extensive practice to maintain the required proficiency for effective application.

• While it presents notable technical challenges, mastering this technique is crucial for enhancing patient safety and outcomes in scenarios where conventional methods may fail or introduce excessive risk. Clinicians must demonstrate equal skill in both rapid sequence induction techniques and awake intubation procedures, ensuring they are prepared for a wide range of clinical challenges.