Awake Intubation in Audio II

aka Own the Airway in Audio 004

Editor’s note: This is the final episode of Minh Le Cong’s ‘Own the Airway in Audio’ series, he will continue to dissect airway topics on his own, brand new blog called PHARM: Prehospital and Retrieval Medicine.

Hi folks!

In this final edition of ‘Own the Airway in Audio’ I speak with Dr Seth Trueger (@MDaware), airway padawan to Mr EMCrit Scott Weingart, about a recent study on awake intubation randomised to flexible fibreoptic or video laryngoscopic tracheal intubation.

Rosenstock CV, Thøgersen B, Afshari A, Christensen AL, Eriksen C, Gätke MR. Awake Fiberoptic or Awake Video Laryngoscopic Tracheal Intubation in Patients with Anticipated Difficult Airway Management: A Randomized Clinical Trial. Anesthesiology. 2012 Apr 5. [Epub ahead of print] PubMed PMID: 22487805.

Here’s the abstract:


Awake flexible fiberoptic intubation (FFI) is the gold standard for management of anticipated difficult tracheal intubation. The purpose of this study was to compare awake FFI to awake McGrath® video laryngoscope, (MVL), (Aircraft Medical, Edinburgh, Scotland, United Kingdom) intubation in patients with an anticipated difficult intubation. The authors examined the hypothesis that MVL intubation would be faster than FFI.


Ninety-three adult patients with anticipated difficult intubation were randomly allocated to awake FFI or awake MVL, patients were given glycopyrrolate, nasal oxygen, topical lidocaine orally, and a transtracheal injection of 100 mg lidocaine. Remifentanil infusion was administered intravenously to a Ramsay sedation score of 2-4. Time to tracheal intubation was recorded by independent assessors. The authors also recorded intubation success on the first attempt, investigators’ evaluation of ease of the technique, and patients reported intubation-discomfort evaluated on a visual analog scale.


Eighty-four patients were eligible for analysis. Time to tracheal intubation was median [interquartile range, IQR] 80 s [IQR 58-117] with FFI and 62 s [IQR 55-109] with MVL (P = 0.17). Intubation success on the first attempt was 79% versus 71% for FFI and MVL, respectively. The median visual analog scale score for ease of intubation was 2 (IQR 1-4) versus 1 (IQR 1-6) for FFI and MVL, respectively. The median visual analog scale score for patients’ assessment of discomfort for both techniques was 2, FFI (IQR 0-3), MVL (IQR 0-4).


The authors found no difference in time to tracheal intubation between awake FFI and awake MVL intubation performed by experienced anesthesiologists in patients with anticipated difficult airway.

We also tackle some listeners’ questions raised by our first interview (Awake Intubation in Audio) plus a few others:

  • What are the pros and cons of the McGrath video laryngoscope?
  • Is there a role for ketamine infusions in awake intubation in the ED?
  • Can beginners perform this awake intubation technique?
  • What about intubating the upper GI bleeder?

These are the key messages from our interview:

  • Consider awake intubation in the anticipated difficult airway. It does not need to be done with a flexible fibreoptic endoscope!
  • Ketamine boluses are effective in achieving successful awake intubation in conjunction with adequate local anaesthesia of the upper airway
  • Awake intubation should be kept simple and not complex. It is a technique that even junior doctors should not feel intimidated by!
  • You can’t topicalise a haemachucker!

… and remember this great clinical pearl:

  • Consider ketamine sedation to facilitate insertion of gastric drainage catheter in the acute upper GIT bleeder!

Listen to the interview (24 min 19 sec) here:

or click here to download the mp3

Credit for audio samples: Seven, The Empire Strikes Back

Here are the word clouds that Seth briefly mentions, showing:

  • things we do for every RSI
  • things we should do for every RSI
  • things we could do for every RSI
  • things we do for an awake intubation

Things we do for every RSI

Things we should do for every RSI

Things we could do for every RSI

Things we do for an awake intubation

Learn more

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