Compiled from a variety of sources from #FOAMed (specifically, NYSORA and the ACCRAC podcast) and inspired by morning report today with Taryn and Tina, here is a quick and dirty rundown for awake intubation. Firstly, we should be considering this method when the two Venn diagrams of “anatomically challenging” and “enthusiastically cooperative” overlap in the emergency department intubation. It’s not often, but the awake technique can maintain airway reflexes and spontaneous ventilation up until the last moment. It’s typically a two-part procedure: topicalization and sedation/intubation. The pharmacologic sedative approach to awake intubation is better detailed in emupdates and EMCrit (parts I and II); however, the following should be a nice guide to the first part: topicalization of the airway.





Topical lidocaine (viscous 2% and liquid 4%)

Nebulized lidocaine (liquid 4%)

Atomizer (MADgic atomizer device)


Tongue depressor

Various small gauge needles




Dry –

Begin by instructing the nurse to administer the glycopyrrolate 0.2 mg IM or IV early before you get started. The glycopyrrolate will take time to kick in; you’ll need some time to get to patient’s secretions to dry up. Alternatively, you can use atropine 0.5-1mg IM or IV as the antisialogogue but watch for hemodynamic effects. Then, begin the process of physically drying out the patient (with the gauze pads) prior to topicalizing them. Use the gauze pads to dab their oropharynx dry off their tongue; the next part won’t work if their mucosa isn’t dry.


Topicalize –

Next, give them lidocaine in many different forms. Nebulized 4% liquid lidocaine should be given at low nebulizer flow rates (~4-8 LPM) to prevent the molecules from going too deep into the tracheobronchial tree–you want to anesthetize their larger airway structures not their alveoli. The patient can also stick out their tongue while inhaling the nebulizer if they’re cooperative enough. Then, topical viscous 2% lidocaine can be given as a “lollipop” where the viscous gel is put on a tongue depressor and dripped down the back of the throat. More topical liquid 4% lidocaine can be sprayed on the tonsillar pillars using the atomizer and then directed farther down toward the glottic structures. Use gauze to hold the patient’s tongue out to visualize the oropharynx.


(Optional) Transtracheal nerve block –

Direct blockade of the recurrent laryngeal nerve is contraindicated because its motor function controls the motors of the larynx. However, blocking the sensory function is depicted in the figure above. It facilitates tolerance of tube passage through the cords. You place a 1-2 mL of 4% lidocaine through the cricoid membrane into the trachea; the patient usually coughs upon administration causing aerosolization of the lidocaine topicalizing the recurrent laryngeal nerve.


Sedation/intubation –

Refer to the aforementioned links/sources for the various methods of sedation to facilitate tube passage. Awake intubation is a spectrum with one extreme consisting of completely cooperative patients and elective procedures; these patients can potentially get away with topicalization only and minimal to no sedation/analgesia/anxiolysis. However, this is unlikely to ever be the patient population in the ED, so titrated sedatives are likely necessary.

June 2024