Airway Management

Preparation and Performance

• Awake tracheal intubation should be considered in patients with predictors of difficult airway management, following a systematic approach focusing on preparation, performance, and post-procedure management to ensure patient safety, as recommended by the Anaesthesia guideline society and the American Society of Anesthesiologists 1
• Maintaining spontaneous ventilation and intrinsic airway tone until the trachea is intubated is a key benefit of awake tracheal intubation, with a success rate of 98-99% and a low complication rate 1
• A cognitive aid or checklist is strongly recommended before and during performance of awake tracheal intubation, to ensure a systematic approach and minimize errors 1
• Sedation should ideally be administered by an independent practitioner, with cautious use of minimal sedation beneficial but not mandatory, and should not substitute for inadequate airway topicalization 1
• Effective topicalization must be established and tested before proceeding, with a maximum lidocaine dose not exceeding 9 mg/kg lean body weight, as recommended by the American Society of Anesthesiologists and the Difficult Airway Society 1, 2
• A combination of bilateral glossopharyngeal nerve blocks, bilateral superior laryngeal nerve blocks, and recurrent laryngeal nerve block is recommended for complete upper airway anesthesia during awake intubation, providing excellent intubating conditions in experienced hands 1
• Phenylephrine 0.5% combined with lidocaine is recommended for nasal routes to reduce epistaxis, according to the Difficult Airway Society and the Anaesthesia guidelines 1, 1
• Cocaine should be avoided due to potential toxic cardiovascular complications, as noted by the Difficult Airway Society and the Anaesthesia guidelines 1, 1

Post-Procedure Management

• Supplemental oxygen should always be administered during the procedure, as recommended by the Anaesthesia guideline society and the American Society of Anesthesiologists 1
• Limit attempts to three, with one further attempt by a more experienced operator (3+1 rule), to ensure patient safety, as recommended by the Difficult Airway Society and the American Society of Anesthesiologists 1, 1
• Verify tracheal tube position with a two-point check, including visual confirmation and capnography to confirm correct placement, and only induce anesthesia after confirming correct tracheal tube position, as recommended by the American Society of Anesthesiologists 1
• Unsuccessful awake tracheal intubation occurs in 1-2% of cases, highlighting the need for careful patient selection and procedure planning 1
• Patients should remain nil by mouth for at least 2 hours following airway topicalization due to the prolonged effect on laryngeal reflexes, and thorough documentation of the technique used is essential for future airway management, as recommended by the American Society of Anesthesiologists 1

Training and Competency

• All departments should support anesthesiologists in attaining and maintaining competency in awake tracheal intubation, with regular practice and simulation essential to maintain skills, as recommended by the American Society of Anesthesiologists 1
• Anesthesiologists should attain and maintain competency in awake tracheal intubation through regular practice and simulation, as recommended by the American Society of Anesthesiologists 1

Special Considerations

• For pediatric patients, lidocaine 2-5% can be applied to the nose and larynx, and conscious sedation with midazolam can be considered for anxious children, as recommended by the American Thoracic Society 3
• Oxygen supplementation is mandatory in young children undergoing nasendoscopy, as noted by the American Thoracic Society 3
• The total local anesthetic dose should be carefully monitored when combining with other procedures requiring local anesthesia, as recommended by the Anaesthesia guidelines 1

Complications and Monitoring

• Patients should be monitored for signs of local anesthetic toxicity, such as lightheadedness, perioral numbness, and tinnitus, and lipid emulsion should be available in case of toxicity, as recommended by the Anaesthesia guidelines 1
• Potential complications, including respiratory depression, hemodynamic instability, and inadequate topicalization leading to cough, laryngospasm, or bronchospasm, should be watched for, according to the American Society of Anesthesiologists and the American Thoracic Society 1, 3
• A cognitive aid or checklist should be used before and during the procedure to ensure a systematic approach, as suggested by the American Society of Anesthesiologists 1
• All necessary equipment, including a flexible bronchoscope or videolaryngoscope, topical anesthetics, sedative medications, oxygen delivery systems, and emergency airway equipment, should be readily available, as recommended by the American Society of Anesthesiologists 1