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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.

Background A new disposable flexible videoscope, the Ambu® aScope, has several potential advantages compared with reusable devices, but it is a prerequisite for its widespread use that it functions sufficiently well in the management of patients in whom difficulty with airway management is anticipated and awake intubation is indicated. Methods In a pilot study, 20 patients with normal airways were intubated with the aScope. Subsequently, 40 patients with predicted difficult tracheal intubation were randomly assigned to be intubated awake with either the aScope or the reusable Olympus BF videobronchoscope. Results All patients were successfully intubated awake. The median total intubation time, including the administration of local anaesthesia, was 278 vs. 234 s in the aScope and Olympus groups, respectively (P = 0.03). In two cases in the aScope group, the image became blurred immediately after the first injection of lidocaine via the injection channel, and the time that it took to replace the scopes was included in the intubation times. Conclusion Both the disposable aScope and the reusable Olympus videoscope allowed safe awake intubation in our elective patients with severely difficult, but uncompromised, airways. The occasional need to employ a spare scope because of malfunctioning would make the disposable aScope less suitable in patients with acutely compromised airways.

Summary A myriad of new intubation equipment has been introduced commercially since the appearance of Macintosh/Miller blades in the 1940s. We review the role of devices that are relevant to current clinical practice based on their presence in the scientific literature. The comparative performance of new vs traditional direct laryngoscopes, their complications, their use in awake intubation techniques and the prediction of unsuccessful intubation with new devices are reviewed. Manikin studies are of limited value in this area. We conclude that in both predicted and unpredicted difficult or failed intubation, carefully selected new intubation equipment has a high success rate for tracheal intubation. Ideally, such devices should be available in all settings where tracheal intubation is performed. Most importantly, experience and competence with any of the new devices are critical for their successful use in any clinical setting.

We studied 21 patients with known difficult airways who underwent awake tracheal intubation using the LMA CTrach. Patients were given midazolam, atropine, a continuous infusion of remifentanil and topical lidocaine applied to the oropharyx. We limited the number of insertion attempts to three and the time to adjust the view to 5 min. In case of failure, we performed awake fibreoptic tracheal intubation. We found insertion of the device was successful and well tolerated in all patients. Vocal cords could be seen immediately in nine patients and following corrective manoeuvres in 10 patients. Tracheal intubation was successful in 20 patients: 19 cases under direct vision and in one blindly. In one patient with undiagnosed lingual tonsil hyperplasia, tracheal intubation was impossible using the device. No patient had an unpleasant recall of the procedure. We conclude that the LMA CTrach is easy to use, well tolerated and suitable for awake orotracheal intubation in patients with known difficult airways.

Summary To examine the education of trainees with regard to difficult airway management, we sent a questionnaire to all 89 Japanese University Departments of Anaesthesia (to be answered by a person who was responsible for teaching trainees) and all 280 Royal College of Anaesthetists' Tutors in the UK. The presence or absence of a formal training module for difficult airway management, timing and methods of training, types of airway devices that should be taught, and tutors' expertise with various techniques and devices were surveyed. Sixty-seven of the 89 Japanese tutors (75%) and 167 of 280 UK tutors (60%) replied to the questionnaire. Only 19 of 67 (28%) Japanese anaesthetists and 33 of 167 (20%) UK anaesthetists who replied, indicated that they had a difficult airway training module. In six Japanese departments (9%) and 115 (69%) UK departments, equipment for percutaneous transtracheal ventilation was readily available. Airway devices and techniques that tutors considered necessary to be mastered in the first 2 years of training, differed considerably between Japan and the UK, with notable differences in the use of gum elastic bougies and awake intubation. A training module for difficult airway management is often not provided and equipment for emergency transtracheal ventilation is often unavailable in both countries.

Background: Problems with managing the airways in relation to anaesthesia causes severe morbidity and mortality. A large proportion of these adverse respiratory events is preventable. Still patients continue to die from airway disasters related to anaesthesia, also in Scandinavia. The goal of this study is to identify which efforts are likely to improve this situation. Methods: A questionnaire asking about experience, behaviour and availability of various items of equipment was mailed to all members of the Danish Society of Anaesthesiologists and were returned anonymously. Results: More than 65% of respondents have sufficient access to a flexible fibrescope, but still 17% of specialists have no access and the vast majority (>67%) has little (1–10 times) or no experience in its use for awake intubation. A total of 52–70% knew the basic principles of the ASA difficult airway algorithm, but despite this only 25–50% would perform awake intubation if a difficult intubation was expected. More than 20% of respondents had experienced preventable airway management mishaps. In all, 18–46% did not know how to oxygenate via the cricothyroid membrane. Conclusion: There is room for improvement regarding airway management skills among Danish anaesthesiologists. It is likely that airway management can be improved by: A) Better knowledge of an appropriate plan, algorithm, for airway management. B) Awake intubation used more often. C) More experience in fibreoptic intubation. D) All anaesthesiologists accepting that previous difficult intubation is an indicator of future difficulties. E) All anaesthesiologists knowing, and practising on manikins, how to oxygenate via the cricothyroid membrane. F) Always having a laryngeal mask airway immediately available when inducing anaesthesia.

A study of 90 patients was undertaken to compare intubation success rates of using either ILMA, C-Trach(TM) or McCoy laryngoscope in patients with simulated cervical spine injury. Insertion and intubation success rates, time taken to achieve intubation, airway complications and haemodynamic parameters were recorded. Insertion of ILMA and C-Trach(TM) was successful at the first attempt in all patients. Intubation success rates were higher in the C-Trach (100%) and McCoy (100%) groups than in the ILMA (87%) group. Total intubation time was significantly longer in the ILMA (63 s, SD 36.5) group than in the C-Trach (41 s, SD 15.8) and McCoy (30 s, SD 7.4) groups (p < 0.05, p < 0.05, respectively). There were no significant differences in haemodynamic parameters among the groups at any time.

The presence of a lateral pharyngeal pouch may cause difficulty in recognising the glottis when awake intubation is undertaken. This is mainly because the orifice may open and close during phonation and therefore be mistaken for the glottis. A case is described and some aspects of relevance to the anaesthetist are discussed.