Awake Tracheal Intubation

01Sex

02Height & weight

Height (cm)

Actual weight (kg)

Pre-filled with a 70 kg, 170 cm male — change these to your patient before relying on the budget.

Topicalisation budget

03Tally what you give (optional)

Sprays of 10% lidocaine10 mg per spray ml of 4% lidocaine40 mg per ml (spray-as-you-go / atomiser) ml of 2% lidocaine20 mg per ml ml of co-phenylcainelidocaine 50 mg/ml + phenylephrine (full bottle 2.5 ml = 125 mg)

0 mg used

Topicalisation notes

Test the block before you start — effective topicalisation must be established and tested. Sedation is not a substitute for it.
The 9 mg/kg ceiling is a maximum, not a target — effective topicalisation rarely needs it. Lower concentrations can be as effective; consider comorbidities.
Lidocaine's effects can persist (elimination half-life up to 2 h) — keep the patient nil by mouth for at least 2 h after topicalisation.
Have LAST provisions in place, including lipid emulsion.

Ahmad I, et al. DAS guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2020;75:509–28 (Table 3 & checklist). Max topical lidocaine 9 mg/kg lean body weight (Grade C). LBW: Janmahasatian 2005.

sTOPThe four components

s

Sedation — minimal, optional. Ideally run by an independent practitioner. Single agent: remifentanil TCI 1–3 ng/ml effect-site, or dexmedetomidine 0.5–1 µg/kg over 5 min then 0.3–0.6 µg/kg/h. Midazolam 0.5–1 mg boluses (peak effect 5–10 min — beware stacking). Avoid remifentanil boluses.

T

Topicalisation. Max lidocaine 9 mg/kg LBW — use the budget above. Co-phenylcaine for the nose; 10% sprays / 4% spray-as-you-go for oropharynx, larynx and trachea. Test before starting.

O

Oxygenation — always. Supplemental O₂ for every ATI from the start; high-flow nasal oxygen is the technique of choice if available.

P

Performance. Full monitoring, optimised ergonomics and setup, and a maximum of 3 + 1 attempts — change something before each one; switching device (FB ↔ VL) counts as an attempt.

ATI works with flexible bronchoscopy or videolaryngoscopy — use whichever you and the patient are best served by.

2ptBefore inducing anaesthesia — two-point check

1 · Visual: tracheal lumen seen with the bronchoscope, or the tube seen passing the cords on the videolaryngoscope.
2 · Capnography: to exclude oesophageal intubation.
Only induce anaesthesia once both confirm tube position.

Unsuccessful ATI — after 3 + 1

Default: postpone. Stop, oxygenate, think.

Immediate: call for help · 100% oxygen · stop (and if needed reverse) sedation · prime for emergency FONA.
Postpone the procedure unless airway management is essential — airway patency, ventilation or neurology compromised; urgent surgery; expected deterioration.
If essential, the preferred route is awake FONA (cricothyroidotomy or tracheostomy) by the most skilled clinician available.
Failing that: high-risk GA — plan an A–D strategy, IV induction with full neuromuscular block, and a videolaryngoscope for the first attempt.

Afterwards

These patients are high-risk at extubation too — plan it with the DAS extubation tool.
Document the ATI and airway findings, and inform the patient.

Ahmad I, et al. Anaesthesia 2020;75:509–28 (Figs 2–4; recommendations 1–8).