Conscious ("Awake") Intubation

While emergency nonanesthetized intubations outside the operating room may be performed with minimal topical anesthesia and no sedation, the term "awake" intubation applied to nonanesthetized intubations in the operating room is usually something of a misnomer. After appropriate sedation, topical anesthesia, and nerve blocks, such intubations can be performed with minimal discomfort in the conscious patient.

Conscious intubation is performed when the clinician believes that it is the safest way to insert an endotracheal tube.

Indications include a history of difficult intubation, findings on history or physical examination that can make intubation difficult, and severe risk for aspiration or hemodynamic instability. The reasons for conscious intubation should be explained to the patient as time allows and documented in the chart. The primary consideration of safety should be emphasized. At times, surgeons (and other physicians) may be unhappy about their patients being subjected to such procedures because of unwarranted fear of patient discomfort and the time required. If the anesthesiologist has concluded that such intubation is indicated, the demands of such individuals must not take precedence over patient safety. The reasons for conscious intubation should be emphasized to the surgeon as well as to the patient because airway disaster, poor outcome, and litigation may follow airway mismanagement.

In the American Society of Anesthesiologists' closed claims study, adverse respiratory events including inadequate ventilation, esophageal intubation, and difficult tracheal intubation form the largest single class of injury