Awake intubation

May 14, 2013 by  
Filed under All Updates, EMS, ICU, Resus

I had some fun today getting intubated.

We used the Ambu aScope 2 and the Greater Sydney Area HEMS equipment and approach to airway management. I didn’t receive an antisialogogue or any analgesia or sedation.

The big learning point for me was how hard it was to anaesthetise the posterior part of my nasal cavity and nasopharynx. I thought the worst part would be any stimulation of my vocal cords or trachea with lidocaine or instrumentation, but this really was fine. Nebulised 2% lidocaine (the strongest concentration we have), atomised lidocaine (using a mucosal atomiser), and co-phenylcaine spray weren’t sufficient. I can see why people use pastes or gel to maintain mucosal contact while the lidocaine takes effect, but we don’t have those (yet). The best solution came from hooking up oxygen tubing to an iv cannula via a three way tap. Oxygen was run through at 2 l/min and lidocaine injected via the the three way tap. This enabled an atomised spray to be directed right onto the area concerned, and made the insertion of the nasotracheal tube more tolerable – although still unpleasant.


The fact I could be intubated awake with reasonable topicalisation suggests most patients should tolerate it perhaps after even an analgesic dose of ketamine, eg. 30-40 mg in an adult. I suspect full dissocation would not be required, which is good for cooperation (“stick your tongue out sir”). I appreciate there are better agents, such as remifentanil or dexmedetomidine, but my area of interest is the retrieval setting – where I have neither the luxury of using these agents nor that of calling for anaesthetic back up.

Thanks to HEMS physicians Emily Stimson, Nirosha De Zoysa, Felicity Day, Chloe Tetlow, and Fergal McCourt for making it fun and safe.

Here’s the video:

Twitter has been helpful in gathering some advice, particularly from @DocJohnHinds:


4 Responses to “Awake intubation”

  1. Karel Habig on May 15th, 2013 14:40

    I guess you will want me to sign-off your Advanced Airway currency…….

  2. Sydney HEMS Supervisor of Training assaulted by registrars…..for training. | Greater Sydney Area HEMS on May 23rd, 2013 11:35

    […] So how does a day proceed from a discussion of cases over morning coffee to intubating a colleague?  Our daily “Coffee and cases’’ review discussion led to a review of the Advanced Airway Currencies and a discussion of the kit available. This, in the interests of increasing the fidelity of our simulation, resulted in Dr Reid requesting to be intubated. For those of you that know Cliff, this will probably not come as a surprise! Exhibiting the true spirit of the FOAM community, Dr Reid had his intubation filmed and has posted it along with an account of his experiences here: […]

  3. Brian on May 26th, 2013 17:24 Well done, Cliff but that looked a lot painful. Check the above link – easiest way to avoid the nasal pain issue : )

  4. Cliff on May 26th, 2013 17:56