Lecture on Awake Intubation

Introduction

• Speaker: Laura Duggan, Associate Professor, University of Ottawa
• Focus: Awake intubation techniques in cases of blunt and penetrating airway trauma.

Importance of Awake Intubation

• Awake intubation is critical despite advancements in video laryngoscopy (VL), especially in anatomically and physiologically difficult airways.
• Successful awake intubation involves minimal sedation and effective airway topicalization.
• Awake techniques are seldom practiced in the operating room, necessitating skill maintenance and evidence-based practice.

Reasons for Awake Intubation

• Anatomically Difficult Airways: Complicated due to conditions like burns, Ludwig's angina, or post-surgical complications.
• Physiologically Difficult Airways: Issues arise due to conditions like pneumonia, pulmonary embolism, or cardiac complications.
• Combined Difficulties: Both anatomical and physiological challenges, such as in patients with obesity or pregnancy.

Strategy for Awake Intubation

• Use patient’s spontaneous breathing rather than inducing positive pressure ventilation.
• Awake intubation allows the patient to maintain their airway protection and gas exchange.

Approach to Awake Intubation

• Glycopyrrolate Administration: Dries secretions and stabilizes heart rate.
• Avoid Sedation: Focus on effective topicalization.
• Equipment Preparation: Ensure organized and accessible equipment.

Topicalization Technique

• Use 4% lidocaine for effective topicalization.
• Target areas:
  • Posterior third of the tongue (trigeminal nerve)
  • Above and below the glottis (vagus nerve branches)
• Application Methods:
  • Atomization for larger droplets; nebulization for smaller droplets.
  • Use 5% lidocaine paste for glossopharyngeal nerve.

Equipment and Methodology

• Use atomizers for precise application of anesthesia.
• Avoid disorganized equipment setups.
• Encourage patient cooperation in airway management.

Technique Preferences

• Video Laryngoscopy (VL) vs. Flexible Scope: Both are effective; VL avoids excessive tissue pressure.
• Avoid direct laryngoscopy due to high tissue pressure.

Common Missteps and Recommendations

• Avoid relying on visual cues alone; trust waveform capnography.
• Be wary of "glottic impersonation" where esophageal walls may look like airways.

Resources and Further Reading

• Difficult Airway Society guidelines: Recommendations for awake intubation.
• Waveform Capnography Studies: Importance of capnography in confirming intubation success.

Skill Maintenance

• Regular use of nasopharyngoscopy as part of airway assessment.
• Collaborate with colleagues to enhance comfort and expertise in awake intubation.