Procedure - Awake Intubation

Question 1

Review the topical anesthestics for awake intubation.

Answer 1

Nasal atomizer: 4 mL of lidocaine in each nare (make sure they’re breathing in while you do it)
Oropharyngeal atomizer: 5 mL of lidocaine sprayed over the tongue, buccal mucosa, and pharynx
Lidocaine jelly or viscous solution applied to the posterior tongue (use gauze to pull the tongue out)

Question 2

Other than anesthesia, what two medicines should you give to prepare for awake intubation?

Answer 2

Glycopyrrolate and ondansetron

Ondansetron is thought to blunt the gag reflex.

Question 3

Review the order of operations for awake intubation.

Answer 3

1) Give ondansetron and glycopyrrolate
2) Anesthetize the airway with lidocaine (nasal atomizer, oropharyngeal atomizer, and viscous lidocaine)
3) Have patient in a semirecumbent position
4) If available, have patient hold an intubating oral airway in their mouth
5) Preload a ETT onto a flexible scope
6) Have sedative and paralytic at bedside
7) Advance tube into laryngoscopic position
8) If larynx is visible, give sedative and advance to trachea
9) Paralyze if unable to intubate with sedative alone