Awake Intubations: “Alone we can do so little, together we can do so much”

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Awake Intubations: “Alone we can do so little, together we can do so much”

Resident Clinical Pearl (RCP) – January 2017

Kalen Leech-Porter, PGY2 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Case Example:

A healthy 60 year old man arrives at the Emergency Department (ED)3 hours after his camp caught fire.  He complains of shortness of breath and he has a hoarse voice. Vitals BP 140/90, HR 95, RR 24, Oxygen saturation 96%, afebrile.  GCS 15. You note he has facial and trunk burns. He is alert, scared but cooperative. How would you definitively manage his airway?

Picture 1.

Introduction:

RSI has gained much popularity in the ED for endotracheal intubation.  While there is good reason for this, there is still a role for awake intubation; with awake intubations the patient continues to breathe for themselves and will maintain and protect their airways.  This can be critically important in a situation where there is an anticipated difficult intubation and difficult bag mask ventilation.  The patient does have to be somewhat cooperative for awake intubation, but with proper explanation this might be the best option in a difficult situation.

Indications:

  • Predicted difficult airway anatomy (intubation AND maintaining oxygenation with BMV)
  • Variations of normal anatomy (ie Mallampati 4, obese, small mandible)
  • Pathologic distortion or obstruction: (ie burns, angioedema, stridor)
  • Predicted difficult physiology
  • Hemodynamic instability- (may still be able to do RSI- using appropriate agents and fluid bolus, but awake intubation is an option)
  • High minute volume – awake intubation will allow them to breathe at their current desired rate until intubation facilitated

Requirements:

  • Patients is awake, cooperative

Advantages of awake Intubation

  • Patient protects/maintains airways
  • Patient breathes spontaneously
  • Less risk of hypoxemia/hypercarbia with transition to positive pressure ventilation
  • May help with intubation: tissue movement/bubbles may indicate glottis opening in obscured airways

Disadvantages

  • Potentially uncomfortable
  • Requires cooperation
  • Procedure can be prolonged

 

Back to our case:

………….the hoarse voice and burns suggest airway edema.  This patient will likely both a difficult intubation and difficult to bag mask ventilate.  However, he is cooperative.  Following the AIME approach to tracheal intubation pathway (below), this patient would be a candidate for awake intubation (red arrow).

AIME approach to tracheal Intubations pathway decision making

 

Generic Approach to awake oral intubation:

  1. Supplemental O2 – consider high flow nasal prongs
  2. Prep:
    1. monitors, O2, BVM, suction, ETTs, stylet, laryngoscope, blades, drugs, alternative intubation options, rescue devices, mark cricothyroid membrane,
    2. Psychologically prepare the patient: tell them rationale and explain procedure
  3. Topical Airway Anesthesia +/- light sedation
  4. Awake intubation
  5. Confirm Tube location
  6. Additional Sedation

More Detailed:

Topical Airway Anesthesia
  1. Consider drying agent to reduce secretions and allow better working of topical anesthesia on mucous membranes: glycopyrrolate 5 micrograms/kg IV
  2. Lidocaine application -don’t add epi
    1. 5% lidocaine ointment with tongue depressor to back of tongue
    2. Gargle and swish 4% liquid lidocaine
    3. Then spray (soft palate, posterior pharynx, tonsillar pillars) as you go with either:
      1. Lidocaine 10% endotracheal spray
      2. 4% lidocaine atomizing device
    4. 4% nebulized lidocaine takes 10-12 mins but is another alternative
  3. Do not exceed toxic dose: 5 mg/kg (use less if elderly or cardiac/liver impairment)
+/- Light Sedation
  1. No sedation is reasonable
  2. Consider ketamine, or midazolam +/- fentanyl in small doses (pros and cons not discussed in this pearl)
Awake intubation using DL

Intubation may be performed with bronchoscopy, glidescope, blind nasotracheal intubation. Below is an abridged description of key points of direct laryngoscopy during awake intubation.

  1. Perform in semi-sitting or sitting position – physician may need to stand on a stool/chair
  2. Use “precision laryngoscopy”, slowly walking the blade in avoiding as many structures as possible
  3. Warn patients they will feel some pressure then compress tongue to visualize epiglottis
  4. Place blade in valleculla and perform appropriate lift to visualize cords
  5. Pass the ETT through the cords while the patient inspires

Picture 2

Post Intubation:

Don’t forget to confirm tube location, and provide sedation if the patients hemodynamics tolerate the sedation!

 

References:

Airway Management in Emergencies: Second Edition.  George Kovacs, J. Adam Law. 2011.

Picture 1

Picture 2

 

 

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