........................................................................

CHAPTER 14

V O L U M E T H I R T Y - S E V E N

AWAKE INTUBATION
MADE EASY!

WILLIAM ROSENBLATT, M.D.

PROFESSOR
YALE UNIVERSITY SCHOOL OF MEDICINE
ANESTHESIOLOGY
NEW HAVEN, CONNECTICUT

EDITOR: MEG A. ROSENBLATT, M.D.

ASSOCIATE EDITORS: JOHN F. BUTTERWORTH IV, M.D.
JEFFREY B. GROSS, M.D.

The American Society of Anesthesiologists, Inc.

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 Awake Intubation Made Easy!

William Rosenblatt, M.D.

Professor
Yale University School of Medicine
Anesthesiology
New Haven, Connecticut

The most taxing part of performing an awake intubation (AI) should be making
the decision that it is needed! When the decision has been made, the means for
securing the airway should be routine for you and comfortable for the patient. This is
not a refresher course on flexible fiberoptic-aided intubation. First, I review a
strategy for determining whether an AI is indicated; then I describe my approach to
patient preparation. Finally, when the patient is prepared, the tool to be used can
vary (e.g., flexible fiberoptic intubation scope, supraglottic airway, direct laryngo-
scope, or videolaryngoscope optical stylet). Importantly, the awake patient may be
sedated and amnestic but should be able to cooperate with procedures and protect
his or her own airway. In some cases, an unconscious and spontaneously breathing
state may be appropriate (e.g., the patient who may be a difficult case for
laryngoscopy but is not at risk for upper airway obstruction or gastric contents
aspiration), but these special circumstances will not be the subject of this discussion.
The clinician must apply his or her own experience and judgment when using the
Airway Approach Algorithm (AAA)---the AAA provides no absolute answers. The
purpose of the AAA is to guide entrance into the American Society of Anesthesio-
logists Difficult Airway Algorithm1 as will be made clear in the following discussion.2

Is Airway Management Required?

Factors including the patients disease and informed consent, consultation with
other physicians, and the anesthesiologists own medical assessment of the patient
determine the answer to this question. It is this authors opinion that the physician
who will assume responsibility for airway management procedures has the most
important opinion. Nevertheless, it is the responsibility of that physician to explain
the rationale for his or her decision to the other parties involved. In some cases,
airway manipulation can be avoided by regional anesthesia. When a decision is made
to proceed without airway manipulation, one should nevertheless conduct a full
evaluation of the patients airway should conversion to a general anesthetic be
required.

Will Laryngoscopy Be Difficult?

The ease of laryngoscopy and intubation must be evaluated in all patients about to
undergo interventions that may affect the airway. Many authors have attempted to
delineate the factors that describe the difficult patient airway. Table 1 lists the most

Copyright 2009 American Society of Anesthesiologists, Inc. 167

168 ROSENBLATT

TABLE 1. Commonly Cited Physical Examination Indices of Laryngoscopy

Physical Examination Index Sensitivity (%) Specificity (%)
Interincisor gap 26 94
Thyromental distance 65 81
Chin protrusion 29 85
Atlanto-occipital extension N/A N/A
Oropharyngeal grade 40-67 52-84

N/A not available.

common techniques in use today. Also included in this table are the results of
sensitivity and specificity testing of these indices. It should be noted that these
standard methods of evaluation have been shown to have low and variable sensitivity
and marginal specificity when used to predict the ease of direct laryngoscopy, and
their sensitivity and specificity for videolaryngoscope remain unknown.3--7 Evaluation
of the airway for the purpose of identifying the difficult-to-intubate patient remains
vexing. There is a continuing search for new predictive physical examination
findings. Overall, the relationship of each test to other anatomic findings is rarely
considered. The published indices tend to treat each physical finding in isolation
from all others, when in fact they are really interdependent.8 Almost no data exist on
the prediction of ease of videolaryngoscopy. If the clinician is satisfied that
laryngoscopy (direct or video) will be straightforward (the answer to question I is
no), then he or she may proceed as seems clinically appropriate given the clinical
needs and the risk of aspiration. This is equivalent to the root point of the American
Society of Anesthesiologists Difficult Airway Algorithm box B (Fig. 1).1 If the
answer to question II is yes, then the AAA proceeds to question III.

The Airway Approach Algorithm

No Consider
I) Must the airway be controlled?
regional/infiltrative
Yes
No
II) Could your laryngoscopy be (at all) difficult?

Yes
III) Could your supralaryngeal ventilation be used (if needed)?
Yes No

IV) Is the stomach empty? (is there an aspiration risk?)

Yes
V) Will the patient tolerate an apneic period?
Yes TTJV

ASA Difficult Airway Algorithm root points

A. Awake intubation B. Intubation attempts after

the induction of anesthesia
Non-emergency pathway Emergency pathway

FIG. 1. A decision tree approach to the preoperative assessment of the patient airway: the
airway approach algorithm.2 Specific to your chosen method of laryngoscopy, e.g., direct or
video. ASA American Society of Anesthesiologist; TTJV transtracheal jet ventilation.
 AWAKE INTUBATION MADE EASY! 169

TABLE 2. Clinical Factors Predictive of Difficulty With Mask

Ventilation10
Age older than 55 years Body mass index 4 26 kg/m2
History of snoring Edentulous
Facial hair

Recent studies have provided some unexpected findings regarding patients who
might present problems with bag and mask ventilation.9,10 Langeron et al.
investigated the delineated clinical factors that described these patients. The study
heightens our awareness that there are a defined number of patient situations in
which one should suspect a problem (Table 2).

Might Supralaryngeal Devices Be Used (If Needed)?

Supralaryngeal devices include the laryngeal mask airway (LMA) and the
Combitube, and both devices can be used in either elective or rescue situations.11
Curiously, only one actual study has investigated the LMA in cannot intubate/cannot
ventilate situations. Parmet et al.11 were able to rescue 16 of 17 cannot intubate/
cannot ventilate patients using the LMA. The single patient who could not be
rescued was found to have intratracheal blood clots, believed secondary to attempts
at transtracheal jet ventilation. The Combitube has been shown to have a 97 to 99%
success rate in prehospital airway rescue in patients who could not be intubated.12,13
Factors that preclude the use of the Combitube and LMA include small mouth
openings, mass lesions in the oropharynx, and full stomach conditions (although
the Combitube and possibly the new Proseal-LMA offer some airway protection
against aspiration14,15). Certain esophageal conditions, including caustic ingestion,
argue against use of the Combitube. New supraglottic airways (e.g., the Laryngeal
Tube, Cobra; VBM Medizintechnik, Sulz, Germany) have also been successfully used
in the cannot intubate/cannot ventilate situation. However, what should one do if
ones assessment leads him or her to suspect that supraglottic ventilation may be
difficult? We have already determined that this patient may be a difficult case for
laryngoscopy (the preoperative equivalent of cannot intubate), and now we have
determined that a possible cannot ventilate scenario might occur. As we never
want to place our patient in danger, box A (AI) is chosen (Fig. 1).1 If it is judged
that supraglottic ventilation will be possible, we proceed to the next AAA question.
Recognizing that the decision regarding supraglottic ventilation adequacy may be
difficult, question V will later address the problem of error.

Is There an Aspiration Risk?

Opinions vary widely as to what patient conditions define a risk for aspiration.
Research regarding gastric-emptying times and the development of new pharma-
ceutical agents has changed the meaning of aspiration risk. If there is a perceived
aspiration risk, then we have reached a potential scenario of cannot intubate and
should not ventilate. When intubation has failed, the American Society of
Anesthesiologists Difficult Airway Algorithm branches to mask ventilation. As mask
170 ROSENBLATT

ventilation is relatively contraindicated in the current assessment, we have once

again found ourselves in the emergency pathway and so will preoperatively choose
box A (AI) (Fig. 1).1 If there is no aspiration risk, we can proceed to the final
question of the AAA.

Will the Patient Tolerate an Apneic Period?

If our assessment of the patient with regard to the difficulty of intubation is
correct, but our assessment of ventilation is erroneous, the patient will experience a
period of apnea after the induction of anesthesia. The duration of apnea will be
dependent on patient health issues and administered drugs. Similarly, the time for
critical oxygen desaturation will vary with patient health as well as the extent of
preoxygenation (a discussion of each of these factors is beyond the scope of the
current lecture16). Should it be determined that the patient would not tolerate a
misjudgment in question III, box A (AI) is chosen.1 If the patient should be able to
tolerate a duration of apnea, which will allow the resumption of spontaneous
ventilation, or provide the clinician enough time to institute alternative rescue
means, routine induction is undertaken (box B) (Fig. 1).1 The experienced
clinician may consider an advanced exception in the failure in judgment decision
branch (question V, answer no). As can be seen in Figure 1, a footnote on the AI
branch indicates that the clinician may consider the feasibility of transtracheal jet
ventilation. Transtracheal jet ventilation can rapidly correct hypoxemia when
initiated promptly and administered correctly. Available equipment (appropriate
catheter and high pressure oxygen source), patient habitus (accessible cricothyroid
membrane), and the physicians experience will dictate the practicality of
transtracheal jet ventilation in the event of oxyhemoglobin desaturation.

Summary of the Decision Making

Airway evaluation should result in a plan that considers all aspects of the patients
airway, not just whether direct laryngoscopy is likely to be easy. Every time we are
asked to manage an airway, or to use pharmaceuticals or perform procedures
that might compromise the patients ability to maintain a patent airway, we
must consider alternatives. The supraglottic airways provide new possibilities in
controlling ventilation. By asking the appropriate questions, all necessary informa-
tion regarding management of the airway is elicited. The cannot intubate or the
cannot intubate/cannot ventilate condition may still arise, but the clinician will be
better prepared, having already gathered the critical information.

Technique of Awake Intubation

AI is a critically important tool. If you manage airways, you must be good at AI
(one day you will need it)! If you have not performed an AI in years, your indications
are probably too restrictive. My experience suggests that the typical anesthesiologist
is insecure about his or her AI technique and confuses airway anesthesia techniques
 AWAKE INTUBATION MADE EASY! 171

TABLE 3. AI Dissected into Six Distinct Elements

Element Underlying concept/action
Explanation Patients understand safety
Desiccation Dry the airway
Dilatation Prepare (through) the nose
Topical anesthesia Obtund reflexes
Sedation Maintain patient airway control
Procrastination Time management

with the AI technique. AI is not about producing a numb airway. The topical
anesthetic(s) chosen matters little. AI involves a systemic approach to patient
preparation. When one has developed a consistent technique, AI can become as easy
as routine airway management (Table 3).

Explanation
All patients presenting to the operating room for surgery harbor some degree of
anxiety. Although we may be comfortable in the operating room, it is a foreign
environment for most others, and surgery is most often a daunting prospect. Patients
want the safest experience possible. If you have determined that AI is warranted, you
have erred on the side of HYPERLINK "mailto:safety@" safety---and the patient will
understand this. A clear explanation to the patient will usually suffice to gain the
patients cooperation. Explaining that they will feel or remember very little and that
they will have some sedation is all that is needed.

Desiccation
To desiccate is to dry. Before you begin to manipulate the airway below the
nasopharynx, it should be dry for a number of important reasons: (1) saliva is a
protective barrier---it will protect the mucosa from your topical local anesthetic
agents; (2) manipulation of the airway produces more secretions---these secre-
tions are an airway stimulant, causing more cough, laryngospasm, etc., and (3)
visualization through an indirect optical device can easily be prevented by excessive
secretions. My favorite desiccant is glycopyrolate (0.2 to 0.4 mg) given intravenously.
Atropine and scopolamine are also effective. Whichever agent you choose, it must be
given time to work---at least 15 minutes. I will often give the dessicant in the patient
intake area as soon as the patient has changed clothes. If there is no intravenous
device in place, I do not hesitate to use an intramuscular injection. This assures that
the agent will have time to be effective. If, by the time the patient reaches the
holding area, they are not complaining of cotton mouth, I consider giving another
0.2 mg.

Dilatation
This is primarily a reminder to prepare the nose, which I do in all cases unless
medically contraindicated, regardless of my intent to intubate via the mouth or nose. A
vasoconstrictor is used to decongest the nasal mucosa. This widens the space and
reduces the risk of bleeding during manipulation. Oxymetazoline (e.g., Afrin; Schering-
Plough Corporation, Kenilworth, NJ; Gensol; Major Pharmaceuticals, Livonia, MI) is
effective and long acting. Why do I prepare the nose in all cases? (1) Local anesthetic
preparation of the nose also anesthetizes parts of the oropharynx by both cross
172 ROSENBLATT

innervation and passive spread of local anesthetic. (2) When oral intubation proves
difficult, the nose is ready to go---too many times I have seen the plan changed from
oral to nasal intubation. Preparation of the nose is often started in the intake area.

Topical Anesthesia
Except for cases of retrograde intubation with a cricothyroid puncture, I do not
use nerve blocks for airway anesthesia. I have no objection to needle blocks; I have
not found them necessary. I use the same topical anesthetic technique in all cases
whether I intend to intubate by a nasal or oral route, regardless of which instrument I
plan to use. I divide the airway into three areas and use directed blocks for each:
nasal passage/nasopharynx, base of tongue/posterior oropharyngeal wall, hypophar-
ynx/larynx--trachea. If the patient coughs during the topical administration, he or she
is told that the local anesthetic is getting to the right place. I also do not use
nebulized local anesthetic; nebulized local anesthetics completely abolish the cough
reflex, which I generally try to avoid.

Nasal Passage/Nasopharynx
This area is innervated by the anterior ethmoid nerve (anterior one-third) and
nasopalantine nerve. I take cotton swabs soaking with local anesthetic (4% lidocaine
solution or 5% lidocaine ointment) and advance them slowly into the nasal passage,
directly posterior until the boney feel of the sphenoid bone is encountered. Progress
is incremental. I advance the swab until the patient winces or otherwise exhibits
discomfort. After a brief hiatus (30 seconds), I continue on. Full anesthesia of the
nose may take as long as 5 minutes to accomplish.

Base of Tongue/Posterior Oropharyngeal Wall

These are the only two areas in the mouth and pharynx that concern me. I do not
concern myself with the oral cavity; my dentist regularly performs an aggressive oral
examination, which I readily accept unless he accidentally stimulates my gag reflex.
The glossopharyngeal nerve is responsible for the gag. We can access the
glossopharyngeal nerve where it travels in the base of the palatoglossal arch---that
arch of tissue, which travels from the uvula to the base of the tongue. A new set of
lidocaine-soaked swabs are inserted along the tongue until they contact the anterior
surface of the base of the arch. Some patients will respond to this with a retch. This
is a good indicator that you are in the correct position. A few moments later, the
swab can generally be reapplied. The patient can close his or her mouth on the
swabs and hold them in position for 5 minutes (Fig. 2).

Hypopharynx/Larynx--Trachea
Many years ago at an American Society of Anesthesiologists annual meeting I
learned a trick from a young anesthesiologist: a 5-ml syringe fitted with a large
plastic angiocatheter is filled with lidocaine (2%). The patient extends the tongue
maximally, and the anesthesiologist takes an unfolded gauze, neatly wraps the tip of
the tongue, and does not allow the patient to retract. After the patient is assured that
there is no needle, the catheter is inserted over the tongue until the distal tip is at the
oral--pharyngeal juncture. Slowly lidocaine is dripped onto the tongue base. The
procedure may take up to 1 to 2 minutes, and all 5 ml of lidocaine need not be used.
At first, the patient will cough. When the coughing subsides, yet you can hear the
gurgling of the lidocaine deep in the airway, you can let go of the tongue. Holding
 AWAKE INTUBATION MADE EASY! 173

FIG. 2. The glossopharyngeal nerve can be blocked with the application of lidocaine on
the inferior aspect of the palatoglossal arch (arrow).

the tongue in this manner prevents the patient from swallowing the lidocaine and
encourages its aspiration.
If a flexible fiberoptic scope is used for the tracheal intubation, local anesthetic
can be injected down the working channel. I prefer a technique I first heard
described by Dr. A. Ovassapian: an epidural catheter is placed via the working port.
Local anesthetic is then administered via the catheter (be sure to cut off a
multiorifice end). This has several advantages: the image is not obscured by the
liquid, the stream can be aimed to the area of need, and suction or oxygen can be
administered at the same time.

Local Anesthetic Accounting

At most I use 400 mg lidocaine (100 mg ointment in the nose and mouth each,
100 mg 2% viscous lidocaine in the hypopharynx, and 100 mg 2% solution via the
fiberscope). Studies have proven this to be an extremely safe level of local
anesthetic, producing peak serum levels of 0.5 mg/ml 11 hours, after administration
(toxic levels being 4 4 mg/ml).17

The Most Difficult Airways

I am often asked by colleagues to advise on the care of patients who have
undergone extensive upper airway surgery and/or radiation. In these patients, nerve
blocks may be difficult or impossible (because of altered anatomy). These airways
are, paradoxically, often the easiest in which to perform AIs! The patients are usually
aware of the anesthetists challenge and are motivated to cooperate. There may be
reduced saliva production resulting from previous radiation and surgical manipula-
tion. There may be postsurgical reduction in sensation.

Sedation
Any of a long list of sedative agents can be used: benzodiazepines, opiods,
droperidol, haldol, benedryl, or dexmedetomidine. There are three rules I follow: (1)
judicious titration---do not give significant boluses of the drugs; (2) avoid poly-
pharmacy---stay with one or two agents; and (3) have reversal agents available. Finally,
do not confuse deep sedation with AI. During AI, the patient should be able to
cooperate with procedures and to control his or her own airway (including coughing).
174 ROSENBLATT

Procrastination
AI is undertaken when the clinician has decided that it is necessary for the well-
being of the patient. As such, the described procedures should be executed at a
controlled pace and in a composed environment. Procrastination is a tongue-in-
cheek way of saying do not rush into the operating room. The operating room is a
highly pressured environment, and it is difficult venue in which to allow adequate
time for antisialogogues and topical anesthetics to produce their therapeutic effect.
We can best achieve our goals by starting our procedures early, if possible, in the
holding area.
Hopefully, now when presented with a patient with a challenging airway, you will
have a strategy for determining whether an AI is indicated and a safe and effective
approach to patient preparation.

References
1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway:
Practice guidelines for management of the difficult airway: An updated report by the
American Society of Anesthesiologists Task Force on Management of the difficult
airway. Anesthesiology 2003; 98:1269--77.
2. Rosenblatt WH: The airway approach algorithm: A decision tree for organizing
preoperative airway information. J Clin Anesth 2004; 16:312--6.
3. Cormack RS, Lehane J: Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39:
1105--11.
4. el-Ganzouri AR, McCarthy RJ, Tuman KJ, Tanck EN, Ivankovich AD: Preoperative airway
assessment: Predictive value of a multivariate risk index. Anesth Analg 1996; 82:
1197--204.
5. Oates JD, Macleod AD, Oates PD, et al.: Comparison of two methods for predicting
difficult intubation. Br J Anaesth 1991; 66:305--9.
6. Yamamoto K, Tsubokawa T, Shibata K, et al.: Predicting difficult intubation with indirect
laryngoscopy. Anesthesiology 1997; 86:316--21.
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planning (supplement). Crit Care Med 2004; 32:S186--92.
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11. Parmet JL, Colonna-Romano P, Horrow JC, et al.: The laryngeal mask airway reliably
provides rescue ventilation in cases of unanticipated difficult tracheal intubation along
with difficult mask ventilation. Anesth Analg 1998; 87:661--5.
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Esophageal tracheal combitube is a useful adjunct. J Trauma 1998; 44:534--7.
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rescue device for paramedic rapid sequence intubation. Acad Emerg Med 2001; 8:500
(Abstract 234).
14. Brimacombe J, Keller C, Fullekrug B, et al.: A multicenter study comparing the Proseal and
Classic laryngeal mask airway in anesthetized, nonparalyzed patients. Anesthesiology
2002; 92:289--95.
15. Brimacombe JR, Berry A: The incidence of aspiration associated with the laryngeal mask
airway: A metaanalysis of published literature. J Clin Anesth 1995; 7:297--305.
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apnoea. Br J Anaesth 1996; 76:284--91.
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application of 2% lidocaine gel. Acta Anaesthesiol Scand 1988; 32:135--9.