Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

I Ahmad, K El-Boghdadly, R Bhagrath, I Hodzovic, A F McNarry, F Mir, E P O'Sullivan, A Patel, M Stacey, D Vaughan, I Ahmad, K El-Boghdadly, R Bhagrath, I Hodzovic, A F McNarry, F Mir, E P O'Sullivan, A Patel, M Stacey, D Vaughan

Abstract

Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high-quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post-tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.

Keywords: airway management; bronchoscopy; laryngoscopy; tracheal intubation; training; videolaryngoscopy.

© 2019 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.

Figures

Figure 1
Figure 1
Examples of ergonomics for awake tracheal intubation (ATI). The primary operator should have a direct line of sight of the patient, video monitor and patient monitor, as well as immediate access to infusion pumps, anaesthetic machine, suction and oxygen delivery device. If a second anaesthetist is present, they should be positioned with a direct line of sight of the patient and have immediate access to infusion pumps, as well as be able to access all other equipment. The anaesthetic assistant's primary position should be with immediate access to the airway trolley, and in proximity to the operator. (a) Awake tracheal intubation performed with the operator positioned facing the patient who is in a sitting up position. (b) Awake tracheal intubation performed with the operator positioned behind the supine/semi‐recumbent patient. This figure forms part of the Difficult Airway Society guidelines for ATI in adults and should be used in conjunction with the text. ©Difficult Airway Society 2019.
Figure 2
Figure 2
The Difficult Airway Society awake tracheal intubation (ATI) technique. This figure forms part of the Difficult Airway Society guidelines for ATI in adults and should be used in conjunction with the text. HFNO, high‐flow nasal oxygen; LA, local anaesthetic; FB, flexible bronchoscopy; MAD, mucosal atomising device; TCI, target‐controlled infusion; Ce, effect‐site concentration; VL, videolaryngoscopy. ©Difficult Airway Society 2019.
Figure 3
Figure 3
Managing procedural complications during awake tracheal intubation (ATI). This provides a framework for managing complications, but is not meant to be a comprehensive guide. This figure forms part of the Difficult Airway Society guidelines for ATI in adults and should be used in conjunction with the text. FIO2, fractional inspired concentration of oxygen; O2, oxygen ©Difficult Airway Society 2019.
Figure 4
Figure 4
The Difficult Airway Society management of unsuccessful awake tracheal intubation (ATI) in adults. This algorithm forms part of the Difficult Airway Society guidelines for ATI in adults and should be used in conjunction with the text. HFNO, high‐flow nasal oxygen; SAD, supraglottic airway device; FONA, front‐of‐neck airway; GA, general anaesthesia. ©Difficult Airway Society 2019.

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