Awake Orotracheal Intubation

Aka: Awake Orotracheal Intubation, Awake Oral Flexible Endoscopic Intubation

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II. Indications: Bronchoscopy mediated orotracheal intubation - Anticipated Difficult Airway

  1. Epiglottitis
  2. Mandible Fracture
  3. Angioedema
  4. Airway Burns
  5. Ludwig's Angina

III. Contraindications

  1. Uncooperative patient
  2. Conditions that obscure scope visibility (airway bleeding)
  3. Persistent Hypoxia (cannot oxygenate scenarios)
    1. Awake intubation requires enough time for effective topical Anesthesia
  4. Apnea
    1. Patients must be maintaining adequate respiratory effort until airway is established

IV. Management: Required Equipment

  1. Flexible fiberoptic scope >60 cm
  2. Intubating Oropharyngeal Airway (e.g. Berman)
    1. Oropharyngeal Airway with a large central hole that accepts an Endotracheal Tube
  3. Endotracheal Tube (7.0 to 8.0)
    1. Warm the Endotracheal Tube in a pocket or warmer to soften
    2. Flexible tip ET Tubes are available (Parker Flex-tip)
  4. Anesthetic
    1. Lidocaine 4% aqueous solution
    2. Lidocaine 4-5% ointment (e.g. LMX)
    3. Anesthesia Applicators
      1. Tongue blades
      2. Cotton-tipped applicators
      3. Atomizers (e.g. MADD, preferably on a tube that can be inserted into posterior pharynx)
  5. Consider Sedation
    1. Avoid if possible
    2. Midazolam 1-2 mg IV in adults
    3. Dexmedetomidine 1 mcg/kg IV over 10 minutes
    4. Ketamine 0.1 to 0.15 mg/kg IV doses in adults
      1. Consider administering in small, 10 mg IV doses
      2. Risk of emergence reaction or Agitation (esp. doses >0.3 mg/kg)
      3. Full dose of Ketamine 1 mg/kg may be given on passing ET Tube

V. Management: General

  1. Consider alternatives
    1. Intubation may be performed via an I-Gel or LMA with an endoscope used through the airway
  2. Position patient in comfortable, semirecumbent position to maximize oxygenation (typically 30 degrees)
    1. Patient placed in upright or semi-upright position (ramp position and reverse trandelenberg)
    2. Assistant performs cervical extension or Jaw Thrust during intubation
  3. Consider patient arm restraints
  4. Continue oxygenation via nose
    1. High Flow Nasal Cannula 30 to 60 L/min (preferred) OR
    2. Nasal Cannula at 15 L/min
  5. Avoid Emesis!
    1. Administer prophylactic Antiemetic (e.g. Ondansetron or Zofran 4-8 mg IV)
  6. Dry the airway
    1. A wet airway is difficult to topicalize with Anesthetic
    2. Suction the airway
    3. Consider drying agents if no significant delay
      1. Glycopyrrolate 0.2 to 0.4 mg IV (wait 2 minutes after administration)

VI. Management: Oropharynx Anesthesia

  1. Adequate topical Anesthesia is critical to success of awake intubation
  2. Anesthetize the Tongue
    1. Cover a Tongue blade with 4 to 5% Lidocaine paste
    2. Place the paste side down over the Tongue and leave in place for 2 minutes
    3. Allow the Lidocaine to drip down the posterior Tongue and posterior pharynx
  3. Reduce the Gag Reflex with a Glossopharyngeal Nerve block
    1. Dip 2 small cotton-tipped applicators in aqueous Lidocaine
    2. Apply 1 applicator to each base of the Tonsillar Pillars
    3. Leave cotton-tipped applicators in place for 2 minutes
  4. Atomize Lidocaine into the posterior pharynx and airway (esp. eliminating Gag Reflex)
    1. Insert the atomizer (e.g. MADD) and spray onto posterior pharynx and peritonsillar pillars
      1. Perform while the patient takes deep breaths
    2. Lidocaine 4% (40 mg/ml) solution with 3-5 ml atomized
      1. May repeat up to a total of 10 ml Lidocaine (max: 9 mg/kg IBW)
  5. Additional Lidocaine is applied to Vocal Cords via scope
    1. See below
    2. Specialized laryngeal atomizing device (MADgic, if available) to topicalize the Vocal Cords
      1. Inserted via Laryngoscope and Lidocaine 4% 3 ml atomized directly at the cords
      2. Device is bent to approximate the Laryngoscope Blade (e.g. hyperangulated glidescope)
  6. Avoid Nebulized Lidocaine
    1. Most of Nebulized Lidocaine is delivered to alveoli
    2. Alveolar Lidocaine absorption may be very high
      1. Increased risk of LAST Reaction when combined with other Anesthetic exposures

VII. Technique: Fiberoptic Oropharyngeal Insertion

  1. Requires adequate topical airway Anesthesia (see above)
    1. Liberal use of topical orotracheal Anesthesia prevents Vomiting (see above)
    2. Any gagging by patient during the procedure should be met with repeat Anesthesia application
  2. Load ET Tube into the Intubating Oropharyngeal Airway
    1. The tube tip should be Preloaded so that it does not protrude yet from the Oropharyngeal Airway
  3. Pass the endoscope into the ET Tube (as it passes through the Oropharyngeal Airway)
    1. The scope will exit the Oropharyngeal Airway just above the Vocal Cords
    2. Use the scope port to spray 4% Lidocaine aqueous solution over the cords before advancing tube
  4. Once endoscope is sufficiently through the Vocal Cords, slide the Endotracheal Tube into position
    1. If unable to advance Endotracheal Tube, consider rotating the tube 90 degrees
  5. Lens fogging
    1. Clean lens with warm soapy water prior to procedure
    2. Flush oxygen through endoscope suction port
    3. Gently tap lens against the mucosa
  6. Once ET Tube is placed within the airway, start induction/start agent (e.g. Ketamine)
    1. Avoid giving full induction dose before ET Tube secured (postural tone may be lost along with airway)
    2. Until tube is placed, use lower Sedative doses for anxiolysis, analgesia (e.g. Ketamine 0.1 mg/kg up to 10-15 mg doses)

VIII. References

  1. (2025) Airway Management, Hospital Procedures Course
  2. Goodwin in Walls (2012) Emergency Airway Management, 3rd Ed, Lippincott, Philadelphia, p. 105-11
  3. Laurin and Schandera (2024) Difficult Airway Course, attended 9/7/2024
  4. Levitan (2013) Practical Airway Management Course, Baltimore
  5. Mason, Herbert, Weingart and Merriman in Herbert (2016) EM:Rap 16(7):10-11
  6. Warrington (2019) Crit Dec Emerg Med 33(12): 14

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