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Awake Tracheal Intubation (ATI) & Awake Front-of-Neck Access–2025 Update
- ATI is recommended when loss of airway patency after induction would place the patient at unacceptable risk (DAS ATI guideline 2020). Success hinges on meticulous planning, patient communication, optimal topical anaesthesia and judicious, titratable sedation.
Oxygenation & Monitoring
| Action | Rationale | Tips |
|---|---|---|
| High-flow nasal oxygen (HFNO) 30–70 L min-¹, FiO₂ 1.0 | Extends safe apnoea time, provides mild CPAP | Start 2–3 min before topicalisation and maintain until tube confirmed |
| Standard monitors + waveform capnography | Early hypoventilation detection | Site EtCO₂ line on scope-mounted sampling port or ETT once placed |
Premedication
| Drug | Dose | Purpose |
|---|---|---|
| Glycopyrronium | 4–6 µg kg-¹ IV/IM (max 400 µg) 15 min pre-procedure | Antisialagogue improves topicalisation |
| Oxymetazoline 0.05 % | 2 sprays per nostril | Vasoconstriction for nasal route, ↓ bleeding |
Airway Topicalisation (“T-pattern”)
- Maximum safe lidocaine 9 mg kg-¹ lean body weight (when adrenaline 1:200 000 used); reduce to 7 mg kg-¹ without vasoconstrictor (AAGBI Safety Guideline 2022).
| Target area | Technique | Typical volume/dose |
|---|---|---|
| Nose | Atomised 4 % lidocaine or co-phenylcaine | 2–4 mL (80–160 mg) |
| Oropharynx / Tongue base | 10 % spray during inspiration (10 mg spray⁻¹) | 5–10 sprays (50–100 mg) |
| SLN (supraglottic) | ‘Spray-as-you-go’ via flexible scope on epiglottis and aryepiglottic folds | 2 mL 2 % (40 mg) each side |
| Trachea / RLN | Cricothyroid puncture or scope working-channel injection | 2–3 mL 2 % (40–60 mg) with cough confirmation |
Nebulised 4 % lidocaine (4–6 mL) can supplement but rarely suffices alone.
Sedation Strategy
| Agent | Regimen | Advantages | Cautions |
|---|---|---|---|
| Dexmedetomidine | Load 1 µg kg-¹ over 10 min then 0.5–0.7 µg kg-¹ h-¹ | Cooperative patient, minimal respiratory depression | Bradycardia, hypotension |
| Remifentanil TCI | Ce 0.5–1 ng mL-¹ (Minto model) | Excellent cough suppression | Apnoea if overshot; titrate slowly |
| Ketamine low dose | 0.25–0.5 mg kg-¹ IV bolus | Maintains airway reflexes, haemodynamics | Dysphoria; combine with midazolam 0.5 mg |
- Use a single agent titrated to Ramsay 2–3 (responds to voice, eyes open). Always maintain verbal contact; keep propofol rescue bolus (10–20 mg) ready if airway stimulation > expectation.
Intubation Technique
Route & Device
- Nasal flexible ATI–best tolerance, leaves mouth free; avoid coagulopathy, basal skull fracture.
- Oral flexible ATI–Berman or Ovassapian airway as conduit if mouth opening ≥ 2 cm.
- Video-laryngoscope ATI–useful skill-transfer, but requires mouth opening; topicalisation depth must abolish gag.
- Hybrid (nasal ETT, oral VL or bronchoscope through tube)–combines advantages in distorted anatomy
Sequence
- Patient seated 45 °; operator maintains eye contact.
- Insert lubricated, anaesthetised NPA (nasal route) to gauge tolerance.
- Advance ETT pre-loaded on scope; visualise cords.
- Instil final 1–2 mL 2 % lidocaine onto cords/trachea.
- Pass tube on inspiration; confirm two-point check: visual + continuous capnography.
- Secure tube → only then induce GA.
Awake Tracheostomy / Front-of-Neck Access
Reserve for “shared-airway” cancer cases or anticipated complete upper airway obstruction.
- Local anaesthetic infiltration (lidocaine 1 % with adrenaline) to skin, strap muscles and trachea.
- Dexmedetomidine ± low-dose ketamine preferred; avoid oversedation.
- HFNO throughout; have rigid bronchoscope/ECMO rescue in theatre.
Complications & Rescue
| Problem | Management |
|---|---|
| Airway obstruction / loss of cooperation | Stop, reassure, improve positioning, increase O₂ flow; suction. |
| Lidocaine toxicity (CNS signs, arrhythmia) | Intralipid 20 % 1.5 mL kg-¹ bolus → 15 mL kg-¹ h-¹; seize control of airway and circulation. |
| Epistaxis | Abandon nasal route, switch to oral or VL; topical adrenaline gauze. |
| Failed intubation (three unsuccessful passes) | Proceed to emergency FONA under local or induce GA for surgical tracheostomy per pre-agreed plan. |
Links
References:
1. Kim CY, Cho S, Ryoo SH. Anesthetic management for emergency tracheostomy in patients with head and neck cancer: a case series. J Dent Anesth Pain Med. 2022 Dec;22(6):457-464. doi: 10.17245/jdapm.2022.22.6.457. Epub 2022 Nov 24. PMID: 36601132; PMCID: PMC9763818.
2. Höhn, A., Kauliņš, T., Hinkelbein, J., Kauliņa, K., Kopp, A. F., Russo, S. G., … & Schröder, S. (2017). Awake tracheotomy in a patient with stridor and dyspnoea caused by a sizeable malignant thyroid tumor: a case report and short review of the literature. Clinical Case Reports, 5(11), 1891-1895. https://doi.org/10.1002/ccr3.1216
3. Higgs A et al. Difficult Airway Society 2020 guidelines for awake tracheal intubation. _Anaesthesia_ 2020;75:509-528.
4. Kwofie K et al. Lidocaine systemic toxicity threshold in ATI: prospective observational study. _Br J Anaesth_ 2024;133:102-109.
5. Sorbello M et al. High-flow nasal oxygen for awake intubation: meta-analysis. _Anesth Analg_ 2023;136:117-126.
6. Riva T et al. Dexmedetomidine vs remifentanil for fibre-optic intubation: randomised trial. _Anesthesiology_ 2022;136:110-121.
7. DAS / ENT-UK joint statement on awake tracheostomy. 2023
8. Vortex Approach. (n.d.). _Best effort airway strategy_. Retrieved February 22, 2025, from https://www.vortexapproach.org/besteffort
Summaries:
Awake intubation
Non intubated thoracic surgery- video
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© 2025 Francois Uys. All Rights Reserved.
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