#81 Awake Intubation

Welcome back to another airway episode! On this episode, Cyrus and Nick are joined by Dr. Jarrod Mosier to discuss advanced concepts of airway management to include a practical and effective approach to awake intubation. We will discuss who is an appropriate candidate for this technique, why and when it should be implemented and cover some important pitfalls and pearls. We hope you guys enjoy this episode and that it motivates you to check out the Difficult Airway Course: Critical Care! If you are interested, make sure you use our discount code CCTIME26 to get $200 off the November course in San Diego!

Our Guest

Jarrod Mosier, MD

Professor of Emergency Medicine and Medicine at the University of Arizona College of Medicine-Tucson.

The Physiologically Difficult Airway

Infographic on Physiologically Difficult Airway

Many peri-intubation complications occur despite first-pass success, including:

• Severe hypoxemia

• Hypotension and cardiovascular collapse

• Worsening acidosis

• Cardiac arrest

The problem is often physiology—not technique.

Phenotypes of the Physiologically Difficult Airway

1. Hypoxemia

   ARDS, pneumonia, pulmonary edema

   Shunt physiology → minimal oxygen reserve

   Even optimal preoxygenation may fail

   Many patients have no safe apnea time

2. Hypotension / Shock

   Induction + positive pressure → ↓ preload, ↓ cardiac output

   Shock Index (HR/SBP) > 0.8 predicts this phenotype. Importantly, even subtle shock matters, for example: HR 100/SBP 100 yields a Shock index of 1.0

3. Severe Metabolic Acidosis

   Tachypnea = life-sustaining compensation

   Paralysis → abrupt loss of ventilation → rapid decompensation

4. Right Ventricular Failure

   Positive pressure → ↑ RV afterload

   Septal shift → ↓ LV filling → collapse

5. Additional Phenotypes

   Pregnancy

   Elevated ICP

   Full stomach / aspiration risk

See our prior episode for more:

Preoxygenation: Necessary but Not Sufficient

• Key Trials

  • PREOXI: NIPPV effective

  • FLORALI-2: NIPPV may outperform HFNC

• Key Takeaways

  • Preoxygenation ≠ guaranteed safety

  • Up to 25% of patients cannot tolerate apnea

  • Shunt physiology + high work of breathing → rapid desaturation

👉 “Preoxygenation implies induction—but not all patients are safely inducible.”

When to Pause Before RSI: Marginal oxygenation despite 100% FiO₂ on NIPPV/HFNC with high work of breathing

• 👉 These patients may depend on their current physiology to survive

• Consider awake intubation instead of RSI

Awake Intubation

• Reframing Awake Intubation

  • Traditional Role: Difficult anatomy

  • Modern Role: Physiologically dangerous airway

• Why It’s Underused

  • Skill decay

  • Clinician discomfort/Cognitive bias

  • Paradox: The highest-risk patients need the least-practiced skill

    • “This mismatch between what guidelines recommend and what clinicians feel comfortable doing creates a profound human factors paradox. While awake tracheal intubation is practiced less commonly, all guidelines now recommend it in these highest risk patients, yet there is significant hesitation clinically. The highest risk patients are those that require the least-practiced skill.”

• Who Should Trigger Awake Intubation?

  • Refractory hypoxemia

  • Severe metabolic acidosis

  • RV failure / pulmonary hypertension

  • Marginal oxygenation or acidosis despite Extreme work of breathing

• These are patients who are surviving because of their current physiology

• Awake Intubation: Practical Approach

  • 1. Decide Early

    • Best done before decompensation.

    • Anyone should be able to safely suggest “would awake intubation be safer here?”

  • 2. Set Expectations

    • Explicitly tell team and patient: “We are doing an awake intubation”

    • Explain to the patient what this means.

  • 3. Position & Oxygenation

    • Upright or semi-upright

    • Continue effective oxygen strategy; often HFNC

  • 4. Preparation

    • Primary + backup airway devices

    • Suction

    • Capnography

    • Bronchoscope/Endoscope

    • ETT tubes (lubed and tested)

    • Equipment for topicalization

      • Atomizer!

      • Lidocaine 4% aqueous solution

      • Lidocaine 5% cream

    • Equipment for rescue plan (typically RSI) VL setup and ready, bougie, etc

  • 5. Technique Selection

    • Flexible scope vs video laryngoscopy

    • Based on anatomy + operator skill

    • Flexible scope often better tolerated

  • 6. Topicalization (Critical Step)

    • Dry the airway: glycopyrrolate 0.005 mg/kg typically 0.2 - 0.4 mg IV

    • First pass atomized lidocaine

      • Atomized not nebulized: “Nebulized lidocaine will not contribute in any meaningful way to airway topicalization… and a large but variable fraction is exhaled…unpredictably increasing the risk of systemic toxicity.”

      • Atomize using 4% aqueous lidocaine

    • 5% Lidocaine ointment to “butter the tongue” using a tongue depressor

      • “Liquifies as it warms and drips down into the base of the palatopharyngeal arches where it penetrates the mucosa and reaches the glossopharyngeal nerve.” Also gets into the valecula, epiglottis, and pyriform recesses, it may also block the superior laryngeal nerve.

    • Second pass atomized lidocaine

    • Test depth of analgesia by touching back of throat. If poorly tolerated add additional topicalization

  • Remember: Max Lidocaine Dose: ~9 mg/kg (lean body weight)

  • 👉 Most common error: under-topicalization

  • Examples of atomizers:

EZ-spray atomizer

MADGic atomizer

• 7. Sedation Strategy

  • Minimal or none if well topicalized; “If topicalization is adequate, many patients require no sedation… however the opposite is not true… There is no amount of sedation or dissociation that removes the requirement for topicalization.”

  • Preserve: Spontaneous breathing & Cooperation

• 8. Tube Placement

  • Without continuous coaching throughout:

  • With ETT loaded on the bronchoscope, hold the scope with two fingers and rest your hand against the patients face. Advance slowly.

  • Apply additional topicalization to the vocal cords through the scope.

  • Slide scope through the cords and advance the ETT over it.

  • If the tube hangs on the cords, gentle counter-clockwise rotation is often sufficient to guide it through.

• 9. Post-Intubation Transition

  • Push medications, connect to ventilator

  • Remember that physiology remains fragile, ensure adequate minute ventilation.

Human Factors & Cognitive Bias

• Why we default to RSI:

  • Familiarity

  • Speed

  • Comfort

• Biases at play:

  • Availability bias

  • Affect heuristic

  • Prospect theory

  • Groupthink

• 👉 Key insight: Clinician comfort ≠ patient safety

Training Implications

• Awake intubation is a perishable skill

• Requires:

  • Simulation

  • Deliberate practice

  • Cognitive rehearsal

• 👉 This is as much decision-making as procedural skill

Be sure to Check Out Dr. Mosier’s new Book: Clinical ECMO Management: A Case-Based Approach

Sponsored by The Difficult Airway Course: Critical Care

• Clinical Trials Discussed

  BOUGIE Trial (2021): A multicenter RCT of 1,102 critically ill adults comparing a bougie-first strategy versus an endotracheal tube with stylet-first. It found no significant difference in first-attempt success rates (80.4% bougie vs. 83.0% stylet) and highlighted that bougie-first use could be associated with longer intubation times and higher rates of severe hypoxemia.

  PREOXI trial (2024) established that preoxygenation with noninvasive ventilation (NIV/BiPAP) significantly reduces hypoxemia during the intubation of critically ill adults compared to a standard oxygen mask

• Related Episodes

  The Physiologically Difficult Airway

  The Anatomically Difficult Airway Part 1

  The Anatomically Difficult Airway Part 2

  Airway Controversies w/ Dr Jarrod Mosier

• References