Awake Tracheal Intubation

• PREPARATION
• Monitoring
• Augment FiO2
• Anticholinergic drying agent- glycopyrrolate
• Topical anaesthesia
• Nerve blocks
• Sedation
• The natural airway is better maintained in awake patients and muscle tone is retained, keeping the upper airway structures and posterior pharyngeal separated from each other.
• With the induction of anaesthesia and paralysis, the larynx moves anteriorly making conventional intubation more difficult.

Topical Anaesthesia

• 4 ml 4% lignocaine ( nonviscous) nebulized directly via the mouth x2 ­ NB must allow sufficient time.
• If nasotracheal intubation is planned, both topical vasoconstrictors (cocaine), and local anaesthetic should be applied to the nose

Nerve Blocks

• Glossopharyngeal nerve
The lingual branch of the glossopharyngeal nerve usually needs to be blocked to ablate the gag reflex when awake direct laryngoscopy is planned.
• Superior laryngeal nerve
Supplies lower pharynx. When this nerve is blocked in conjunction with the above, awake direct laryngoscopy is possible.

Sedation

• Degree of sedation required depends primarily on how well the airway is prepared topically
• Must maintain meaningful contact with the patient.
• Remifentanil 0.05-0.15 mcg/kg/min reduces anxiety and increases the pain threshold. This should be started at the lowest rate and cautiously increased as the need arises.

Choice of Intubation Technique

• Direct laryngoscopy
• Blind intubation
• Flexible fibreoptic intubation

Flexible Fibreoptic Intubation

• Can be performed via the nasal or oral route, with or without a stiff conduit designed to bring the scope close to the laryngeal aperture without any manipulation on the part of the operator.
• Nasal ­ nasal tube ( presoftened in hot H2O)
• Oral ­ Berman, Ovassapian or Laryngeal mask

Flexible Fibreoptic Intubation

• Before insertion, the FOB should be lubricated and an appropriately sized ETT threaded over its proximal end. O2 can be insufflated down the FOB to augment FiO2 and blow away secretions.
• Once the FOB is above the cords it may be necessary to spray the cords with lignocaine via the side-port.
• After the FOB has been passed into the trachea the ETT can be threaded over it and the FOB withdrawn.The ETT adaptor is inserted and the tube connected to the circuit, position of the ETT is confirmed with capnography.

Special Techniques

• Special laryngoscope blades and the Lightwand
• Awake Tracheal Intubation
Direct
Blind
Fibreoptic
• Trans-tracheal Jet ventilation
• Retrograde intubation
• Laryngeal mask and Intubating laryngeal mask
• Combitube
• Tracheostomy

Anaesthetized patient

• All the listed techniques can be used in the anaesthetized patient
• Must maintain gas exchange during intubation techniques via mask ventilation or Laryngeal mask
• Always consider the possibility of waking the patient up before the ability to maintain ventilation is lost due to airway bleeding or oedema
• If there is nothing new to be tried, wake the patient up