Topical Anesthesia for Awake Intubations

An awake intubation allows the patient to continue breathing during the intubation.

Equipment:

A flexible endoscope (or laryngoscope), 5% lidocaine gel, 4% lidocaine liquid solution to aerosolize, atomizer device (EZ-Spray is shown), nasal mucosal atomizer, gauze, tongue depressor, warm water, and an endotracheal tube.

Step 1: Lidocaine lollipop

Place a dollop of the 5% lidocaine gel on the tip of a tongue depressor. Have the patient extrude their tongue and hold it gently with the gauze. Apply the lidocaine gel to the posterior tongue and let the gel melt towards the posterior tongue. Repeat multiple times.

Step 2: Atomized lidocaine

Have the patient take a deep breath as you atomize the 4% liquid lidocaine solution to the posterior pharynx and hypopharynx. (Optional: Use a nasal mucosal atomizer to anesthetize the nasopharynx.) Repeat multiple times.

Step 3: Laryngoscope

With the patient sitting upright, place the laryngoscope and have the patient hold it. This acts as a runway to pass the proximal structures of the oropharynx. Advance the flexible endoscope to visualize the vocal cords.

Step 4: Endotracheal tube

Load the endotracheal tube on the flexible endoscope and advance the flexible endoscope until the vocal cords are visualized.

This video is a demonstration, but on a real patient, you would advance the flexible endoscope past the cords and then slide the endotracheal tube over the flexible endoscope. Once in place, the patient can be fully sedated.

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