The gold standard for awake intubation is by flexible fiberoptic scope. With good reason. In trained hands, the fiberoptic scope is the best and most flexible and versatile method. But it takes practice. With modern technology, there’s an easier way.

We know how to do laryngoscopy. And these days, most departments have a video laryngoscope available. It lets you see around corners, so you don’t have to lift the laryngoscope so much to get a good view. Less lifting gives less discomfort for the patient.

So with a standard awake intubation preparation with topical anaesthesia and low dose remifentanil infusion, the patient has good analgesia, is sedated, but arousable, and self ventilating. And you are ready for video laryngoscopy. Go ahead carefully and slowly. If the patient reacts, withdraw and give more topical anaesthesia or increase the remifentanil infusion. Usually, you will easily get a good view.

Alternatively, the awake intubation can be done with topical anaesthesia only, add a little opioid or add a little sedation, like propofol or midazolam to lessen the discomfort by taking the edge off the nervousness (the patient’s, not yours).

Finish off in the standard fashion: Put down the tube with a stylet or bougie, inflate the cuff, verify the position with capnography and induce with propofol.

Do a thorough pre-operative assessment before going ahead with this, and inform the patient carefully. You might also want to have a fiberscope and fiberscope operator available. Follow standard awake intubation procedure. If you can’t get a good view, stop the remifentanil infusion to wake up the patient and abort the procedure.

It’s an elegant way to do an awake intubation with less fuzz than the fiberscope way, and no fiberscope to clean afterwards.

On PubMed I could only find case reports and small series of awake intubations using video laryngoscopes, which is the same sort of experience I have myself. But do a search if you want to read some case reports

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  1. Gavin Doolan says:

    I’ve been using the awake look with a videoscope and topicalisation only for a while now. A really important aspect is patient cooperation. Talking them through the procedure while you are doing it really helps. I have found using the McGrath or Glidescope is easy, but the Pentax blade is too big, and less well tolerated. Lastly, if you have a patient who can’t lie down you can try an awake look from in front of the patient.

    • Thomas D says:

      Thanks Gavin! That’s certainly one of the most important points: patient information to make the patient feel at ease and be comfortable and cooperative. With good patient cooperation, it’s certainly possible to do with topical anaesthesia only.
      Interesting observation on the Pentax VL blade. I’ve almost exclusively used the McGrath. I’ve never tried standing in front of the patient with the VL held like an ice pick, but it makes sense. And with the external monitor, you would still get a ‘normal’ view while holding the VL upside down – does that give you a bit of hand-eye coordination problems, or is it easy to adopt to?

  2. Jimmy D says:

    I know this post is “old”, but I feel compelled to add a little something to it. In cases of predicted difficult intubation, the concepts and techniques are the way forward on my opinion, but don’t toss away the bronchoscope yet. In cases of tumor, the bronchoscope must be used to examine the airway, and an informed decision can be made to proceed from there. I had a patient come back to me this week who I had been involved in treating 2 years ago (laryngeal cancer)–her recurrence of the cancer produced a scenario in which the Glidescope caused almost intractable bleeding in her pharynx almost instantly–a flexible fiberoptic (through a pool of blood) saved her life. I was assisting one of my colleagues (who’s plan A was the Glidescope), and I was his “plan B”. I did not want to take the case away from a senior partner, although I am the specialist in my group that handles nasty airways. Thanks for everything, your blog is tremendous!

    • Thomas D says:

      Thanks for your input and kind comments – and for an interesting and scary story! It’s flattering to be plan B, but it works best if you’re informed of your part in the plan beforehand. Nice save, though! One of the most difficult parts of difficult airways is that they’re often so damn difficult to predict! So I try to live by the Monty Python mantra: Always expect the Spanish Inquisition!

      If the Glidescope was used on an awake patient, wouldn’t the patient be able to keep an open airway in a sitting or lateral position? Patients with massive posterior nose bleeds can usually keep their airways – as long as they don’t panic – or was this bleeding simply too torrential?

      I do agree, though, the flexible scope is still the gold standard and can help you out in scenarios where the video laryngoscope will fail. One worry with the video laryngoscopes is that we get less training with the flexible scopes, so I’ll use any excuse to pull out the flexible scope instead.

      BTW, I’m glad you comment on ‘old’ posts. In this internet era, it sometimes feels like things are only relevant a day or two. Hopefully that’s not true.

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