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RSI is our go-to method of intubation in the ED and ICU. However, not all patients are appropriate candidates for RSI. For some patients, maintaining spontaneous respirations until the tube is in between the cords is far safer. Developing a comfort level with awake intubation is a helpful tool in a practitioner’s airway arsenal.

The posterior fossa and craniovertebral junction are well known to surgeons as neuroanatomically critical locations with a myriad of complex and sensitive structures packed into a small area. It is often said that benign lesions in this part of the brain are in a malignant location. Anesthesia for such surgeries is also appropriately recognized as complex and presents unique challenges for the anesthesiologist as well. The choice of anesthesia technique and agents based on the neurophysiologic monitoring anticipated, induction and intubation challenges, unique patient positioning requirements, as well as postoperative airway decisions pertaining to adequacy of gag and swallow reflexes, all lend to the special challenges. For this reason, a thorough conversation should be had prior to the induction of anesthesia between the surgeon, neurophysiologic monitoring personnel and anesthesiologist as to the particulars of the case at hand.

Despite recent advancements in video and digital laryngoscopes, awake intubation continues to be an important modality for anesthesiologists to secure the airway. Awake intubation (AI) can be performed for a variety of conditions that can result in a difficult airway. Congenital anomalies involving the head and neck, tumors of the airway, morbid obesity, cervical spine pathology, and trauma associated with facial and cervical instability all make direct laryngoscopy challenging and can be indications for awake intubation.

Diagnostic Verification of endotracheal (ET) tube position. Collection of bronchial secretions for cultures. Identification of hemoptysis source. Thoracic trauma. Evaluation of inhalation injuries. Therapeutic Awake intubation. Clearance of retained secretions. Foreign body/mucus plug removal. Guidance to bedside percutaneous tracheostomy placement. Balloon placement/selective airway intubation in cases of massive hemoptysis.

You find yourself in a foreign land on a medical mission with plastic surgeons repairing facial deformities. As the only anesthesiologist, you are in charge of the anesthesia equipment. You are requested to anesthetize a large man (180 kg) for removal of scars from his face. His neck is over 40 cm in diameter. Unfortunately, your box with airway equipment like a fiber-optic scope, gum elastic bougies, etc. has not yet arrived. Through a translator (you don’t speak his language) you tell him them you would like to attempt an awake intubation under local anesthesia. The patient is terrified and wants to be asleep. You realize that you may need to have a gum elastic bougie as a backup. You start looking for possible ways of making a bougie from what you have available. The 18 Fr nasogastric tube would be too soft and the suction catheters you have are too short.