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

Abstract

Summary 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.

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

“…This includes utilisation of cognitive aids such as checklists, cross-checking and pre-planned and explicitly defined airway management strategies [36]. Any airway management procedure should be managed electively should guide clinicians to determine the safety of asleep tracheal intubation, rather than awake tracheal intubation (ATI) [37,38]. Clinicians must note that ATI is potentially a highly aerosol-generating procedure, thus the decision to undertake ATI must be carefully considered.…”

Maintaining competence in airway management

“…In our study, 62% of anaesthesiologists in anaesthesia performed awake FOI ≤4 times yearly, which is more frequent than among the members of The Difficult Airway Society, where a recent survey demonstrated that 92% of the anaesthesiologists performed awake FOI ≤5 times yearly . Awake FOI should be an option in all departments day‐and‐night, which effectively mandates all anaesthesiologists to maintain their skills lifelong despite the limited training opportunities identified in both our study and many previous studies …”

A multidisciplinary approach for managing the infraglottic difficult airway in the setting of the Coronavirus pandemic

“…19 Awake Tracheal Intubation should be performed in accordance with the Difficult Airway Society guidelines. 20 Different considerations apply when managing extrathoracic and intrathoracic airways. Lesions of the subglottis and the cervical trachea may be accessed via suspension laryngoscopy and are amenable to jet ventilation or THRIVE.…”