The decision for an awake intubation may be based on a history of difficult ventilation and/or intubation during prior anesthesia. The indication for surgery may require awake intubation. For example, you may be asked to anesthetize a patient with severe cervical spine instability, requiring awake intubation and awake positioning; or a patient might have a head and neck mass that is partially obstructing the airway or compressing the trachea. Information obtained from history and physical examination is also useful and may reveal congenital syndromes, abnormal facial structure such as micrognathia, morbid obesity, obstructive sleep apnea with poor respiratory reserve, severe aspiration risk, or significant hemodynamic instability.

Most intubations are performed orally, unless there is a contraindication. Nasal intubations are used for oral surgeries in which an endotracheal tube would hinder the operation, or if the mandible is to be wired closed. Nasal intubation can be performed on patients with poor mouth opening and to aid patient comfort and oral hygiene if immediate postoperative extubation is not planned. Fiber-optic nasal intubation is often technically easier
than oral fiber-optic intubation, and a blind nasal intubation can also be employed.

Contraindications to nasal intubation include coagulopathy, abnormal nasal anatomy, sinusitis, and facial trauma where there may be a basilar skull fracture. Complications of nasal intubation include epistaxis, trauma to nasal structures, sinusitis with possible bacteremia, and cribriform plate perforation resulting in cerebral injury/death.

There are multiple ways to perform an awake intubation. Common to all awake techniques is preparation of the patient and the airway. Letting the patient know what to expect is a key component to success. Mild sedation, as respiratory status permits, is also helpful. Preparation of the airway includes administration of antisialagogues and anesthetization of the airway with topical and regional techniques (see Chapter 4).

Currently, the most commonly employed technique is oral or nasal fiberoptic intubation. Keep in mind that fiber-optic scopes are not always available and are not a requirement for awake intubation. Other options include blind nasal intubation, laryngoscopy, or some combination of techniques. Keep in mind that an ultimate option may be a surgical airway.