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• W4282968997 abstract "Learning objectivesBy reading this article, you should be able to:•Explain the predictors of the difficult airway and the techniques required for awake tracheal intubation (ATI).•Describe approaches to airway preparation, oxygenation and sedation during awake airway techniques.•Outline the considerations of managing unsuccessful ATI.•Develop an approach to improved training and familiarity with ATI.Key points•Awake tracheal intubation (ATI) remains the gold standard for airway management in the patient with a predicted difficult airway.•ATI should be considered in any case with predictors of difficult airway management.•ATI encompasses techniques using both flexible bronchoscopy and videolaryngoscopy.•Careful airway preparation, sedation and consideration of ergonomics can significantly improve the success rate of ATI.•A stepwise approach to training in ATI will improve technical performance. By reading this article, you should be able to:•Explain the predictors of the difficult airway and the techniques required for awake tracheal intubation (ATI).•Describe approaches to airway preparation, oxygenation and sedation during awake airway techniques.•Outline the considerations of managing unsuccessful ATI.•Develop an approach to improved training and familiarity with ATI. •Awake tracheal intubation (ATI) remains the gold standard for airway management in the patient with a predicted difficult airway.•ATI should be considered in any case with predictors of difficult airway management.•ATI encompasses techniques using both flexible bronchoscopy and videolaryngoscopy.•Careful airway preparation, sedation and consideration of ergonomics can significantly improve the success rate of ATI.•A stepwise approach to training in ATI will improve technical performance. Awake tracheal intubation (ATI) is defined as successful placement of a tracheal tube in a patient who is awake and breathing spontaneously. It comprises several techniques aimed at successfully securing the airway of patients in whom factors may predict difficult airway management. Awake tracheal intubation remains the gold standard for management of the anticipated difficult airway, because of its high success rates and low risk profile. However, ATI accounts for only <0.2% of tracheal intubations performed annually in the UK, in contrast to the higher reported rates of difficult tracheal intubation or facemask ventilation.1Royal College of AnaesthetistsThe NAP4 report: major complications of airway management in the United Kingdom.2011Google Scholar The recently published Difficult Airway Society (DAS) ATI guidelines highlight that ATI remains a core skill and present the opinion of airway experts alongside the best available evidence to support the performance of ATI. The recommended practice may reduce the barriers to performance of ATI when indicated. The ability to secure the airway of a patient who maintains their intrinsic airway tone underpins the superior safety profile of ATI over techniques with the patient sedated heavily or anaesthetised.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar The term ATI encompasses a number of techniques. Traditionally, ATI with a flexible bronchoscope (ATI:FB) was most commonly performed; more recently ATI with videolaryngoscopy (ATI:VL) has developed into a core technique.3Leslie D Stacey M Awake Intubation.Contin Educ Anaesth Crit Care Pain. 2015; 15 (64–7)Abstract Full Text Full Text PDF Scopus (25) Google Scholar No single technique has been demonstrated to be superior when both are possible, except in patients with significantly limited mouth opening, tongue or neck deformity. In these situations ATI:FB may be the preferred modality.3Leslie D Stacey M Awake Intubation.Contin Educ Anaesth Crit Care Pain. 2015; 15 (64–7)Abstract Full Text Full Text PDF Scopus (25) Google Scholar A dual technique, called video-assisted flexible/fibreoptic intubation (VAFI), requiring both a videolaryngoscope and a bronchoscope has also become increasingly used.4Saunders T.G. Gibbins M.L. Seller C.A. et al.Videolaryngoscope-assisted flexible intubation tracheal tube exchange in a patient with a difficult airway.Anaesth Rep. 2019; 7: 22-25Crossref PubMed Scopus (7) Google Scholar The term ATI may also be expanded to include ATI with front-of-neck airway and awake tracheostomy, but this article will focus upon conventional intubation with a tracheal tube.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar ATI is indicated in any patient with predictors of difficult tracheal intubation or face mask ventilation; these may stem from pre-existing patient factors or as a consequence of the presenting pathology.5Crawley S.M. Dalton A.J. Predicting the difficult airway.BJA Educ. 2015; 15: 253-257Abstract Full Text Full Text PDF Scopus (46) Google Scholar In cases of recognised difficult laryngoscopy and tracheal intubation, where facemask ventilation is possible, asleep techniques may be considered more appropriate, and it is useful to develop these skills for the management of the unpredicted difficult airway. Absolute contraindications to ATI are limited only to the patient's refusal, despite appropriate explanation. Relative contraindications include: allergy to local anaesthetic, airway bleeding (where blood may obscure the image achieved through a flexible bronchoscope or videolaryngoscope), the uncooperative patient and certain airway tumours (with the potential to cause a ‘cork-in-bottle’ airway obstruction).3Leslie D Stacey M Awake Intubation.Contin Educ Anaesth Crit Care Pain. 2015; 15 (64–7)Abstract Full Text Full Text PDF Scopus (25) Google Scholar Fibreoptic intubation was first performed in the 1960s and thereafter, bronchoscopes have become a mainstay of difficult airway management. The oral or nasal route for ATI:FB should be selected carefully, based upon factors related to the patient, surgical access and the equipment available. No single route has been shown to be superior when both are possible.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar The length, tip design and material must be considered when choosing the tracheal tube for performing ATI:FB. Railroading (passing the tracheal tube over the flexible bronchoscope) and impingement on the larynx are potential barriers to successful ATI:FB. Numerous tracheal tubes can be used for ATI:FB; reinforced flexometallic, intubating laryngeal mask airway (ILMA) and nasotracheal tubes can all be used.3Leslie D Stacey M Awake Intubation.Contin Educ Anaesth Crit Care Pain. 2015; 15 (64–7)Abstract Full Text Full Text PDF Scopus (25) Google Scholar The size and external diameter of flexible bronchoscope selected for ATI:FB should also be part of decision making. The authors choose to preload the flexible bronchoscope with a size 6.0 cuffed ILMA tube. The soft tip and malleability mean that it is suitable for both oral and nasal routes of intubation, and is less likely to impinge on the larynx during railroading. Videolaryngoscopy has increased in popularity over recent years. The COVID-19 pandemic has seen its use further encouraged in and out of the operating theatre, and it has been further recommended as the default airway management technique as we enter the endemic phase of the disease.6Cook T.M. El-Boghdadly K. McGuire B. et al.Consensus guidelines for managing the airway in patients with COVID-19.Anaesthesia. 2020; 75: 785-799Crossref PubMed Scopus (633) Google Scholar Its advantages include technical familiarity with a similar success rate and safety profile to ATI:FB.7Alhomary M. Ramadan E. Curran E. Walsh S.R. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis.Anaesthesia. 2018; 73: 1151-1161Crossref PubMed Scopus (91) Google Scholar ATI:VL does not affect time to intubation, when compared with ATI:FB.8Rosenstock C.V. Thøgersen B. Afshari A. Christensen A.L. Eriksen C. Gatke M.R. Awake fibreoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management—a randomized clinical trial.Anesthesiology. 2012; 116: 1210-1263Crossref PubMed Scopus (169) Google Scholar In addition, no further considerations are needed in respect of tracheal tube selection over an anaesthetist's normal practice. However, additional equipment such as a bougie or stylet should be prepared.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar At present, no single videolaryngoscope has been shown to be superior for ATI:VL and therefore current recommendations suggest using the equipment with which the operator is most familiar.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar A number of case reports have described a technique using both flexible bronchoscopy and videolaryngoscopy, in order to achieve successful tracheal intubation in the awake patient where ATI:FB alone may have failed. It requires a minimum of two experienced operators, the first using videolaryngoscopy to optimise the view of the larynx and displace the epiglottis. The second operator uses the flexible bronchoscope as a steerable bougie to intubate the trachea and subsequently use the bronchoscope as an introducer for the tracheal tube.4Saunders T.G. Gibbins M.L. Seller C.A. et al.Videolaryngoscope-assisted flexible intubation tracheal tube exchange in a patient with a difficult airway.Anaesth Rep. 2019; 7: 22-25Crossref PubMed Scopus (7) Google Scholar,9Gómez-Ríos M.Á. Nieto Serradilla L. Combined use of an Airtraq® optical laryngoscope, Airtraq video camera, Airtraq wireless monitor, and a fibreoptic bronchoscope after failed tracheal intubation.Can J Anesth. 2011; 58: 411-412Crossref PubMed Scopus (19) Google Scholar, 10Chung M.Y. Park B. Seo J. Kim C.J. Successful airway management with combined use of McGrath® MAC video laryngoscope and fiberoptic bronchoscope in a severe obese patient with huge goiter – a case report.Korean J Anaesth. 2018; 71: 232-236Crossref PubMed Scopus (17) Google Scholar, 11Liew G.H.C. Wong T.G.L. Lu A. Kothandan H. Combined use of the Glidescope and flexible fibrescope as a rescue technique in a difficult airway.Proc Singap Healthc. 2015; 24: 117-120Crossref Scopus (9) Google Scholar ATI, especially in the context of difficult airway management, is associated with considerable stress for the operator. Consequently, preparation, planning, teamwork and communication are all essential for optimal performance.12Miller T. Miller T. McCann A. Stacey M. Groom P. Cognitive psychology, the multidisciplinary operating theatre team, and managing a cannot intubate, cannot oxygenate emergency.Br J Anaesth. 2020; 125: e12ee15Abstract Full Text Full Text PDF Scopus (4) Google Scholar Recent guidelines support clinical experience that the operatong theatre environment is the optimal location for performing ATI.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar Association of Anaesthetists guidelines for patients receiving sedation should be followed.13Association of Anaesthetists of Great Britain and IrelandRecommendations for standards of monitoring during anaesthesia and recovery.Anaesthesia. 2016; 71: 85-93Crossref PubMed Scopus (339) Google Scholar A second anaesthetist should be present and responsible for injecting and monitoring the effects of sedation. The importance of well-trained assistants cannot be overestimated and checklists form an aide memoire in clinical emergencies. The DAS has produced a checklist that can be updated for local practice (Fig 1). As a procedure that is performed infrequently by many anaesthetists, this checklist provides an easily accessible point of reference, and aims to both increase the use of ATI where indicated, and improve its safety when performed. Ergonomics contribute to successful performance of technical skills.14Davis M. Hignett S. Hillier S. Hames N. Hodder S. Safer anaesthetic rooms: human factors/ergonomics analysis of work practices.J Perioper Pract. 2016; 26: 274-280PubMed Google Scholar No individual set up has been shown to be superior, but one possible layout as suggested by DAS is illustrated (Fig 2). The authors advise that operator, bronchoscope, patient and screen are aligned for optimal comfort.3Leslie D Stacey M Awake Intubation.Contin Educ Anaesth Crit Care Pain. 2015; 15 (64–7)Abstract Full Text Full Text PDF Scopus (25) Google Scholar Positioning the patient in the semirecumbent position offers anatomical and physiological advantages to performing ATI.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google ScholarFig 2Suggested ergonomics for the performance of awake tracheal intubation. Alongside pictorial representation of the ergonomics and equipment required.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The indications and clinical scenarios where ATI is considered mandates the use of supplementary oxygen therapy. The incidence of desaturation (Spo2 <90%) varies depending on the delivery device. High-flow nasal oxygen (HFNO) is the authors' oxygen delivery method of choice with reports of lower incidence of desaturation when compared with low-flow devices.15El-Boghdadly K. Onwochei D.N. Cuddihy J. et al.A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre.Anaesthesia. 2017; 72: 694-703Crossref PubMed Scopus (71) Google Scholar Traditional nasal cannulae or an inverted Hudson mask offer alternative options where HFNO is unavailable. Adequate airway topical anaesthesia is vital to the success of ATI approaches and lidocaine is commonly used for this purpose. It is available in a variety of pharmaceutical preparations, including combination with vasoconstrictors (such as adrenaline [epinephrine] and phenylephrine) which reduce the likelihood of epistaxis when nasal intubation is preferred.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar The maximum prescribed dose for topical anaesthesia is 9 mg kg−1, although in practice doses this high should not be required by those experienced in ATI. Cocaine has the advantage of intrinsic vasoconstrictor activity but concerns regarding its adverse cardiovascular effects mean its use is no longer recommended. Local anaesthetics can be nebulised, given by a ‘spray-as-you-go’ technique, via a variety of devices, or via nerve blocks to the superior laryngeal and glossopharyngeal nerves.16Sudheer P. Stacey M.R. Anaesthesia for awake intubation.BJA CEPD Rev. 2003; 3: 120-123Abstract Full Text PDF Scopus (6) Google Scholar There is insufficient evidence to recommend a single technique, but nerve blocks are associated with increased plasma concentrations of local anaesthetic.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar Variation in practice may exist between anaesthetists for achieving airway anaesthesia. The authors' preferred method has proved effective over years of clinical use and is outlined below (Table 1).Table 1Authors' technique for ATI. MAD, mucosal atomisation device; TCI target-controlled infusion; TT, tracheal tube.Local anaesthetic techniqueSedationInstructions to patientTimeNoseCophenylcaine (0.5 ml) via MAD to each nostrilSecond anaesthetist to manage sedation0 min5 minPharynxLidocaine 10% spray (10 mg per spray)•≥1 Spray to tip of tongue•≥6 Sprays to base of each tonsillar pillarRemifentanil TCIStart with low target concentration (e.g. 0.5–1 ng ml−1)Increase to maximum 3 ng ml−1 (0.5 ng ml−1 increments)LarynxLidocaine 2% via epidural catheter inserted via suction port of scope.•2 ml above vocal cords•2 ml below vocal cordsPass scope through cordsPass TT through cords(Alternative injection via MAD if ATI:VL preferred)Deep breath 1Deep breath 2Deep breath 3Deep breath 4 Open table in a new tab Cricothyroid puncture and transtracheal local anaesthetic injection can provide airway anaesthesia. In addition, if performed with a suitable cannula, it can be used for rescue oxygenation, and provide a conduit for passage of a guidewire facilitating Seldinger tracheostomy in cases of failed intubation or airway obstruction. Adequate airway topical anaesthesia is vital to the success of ATI techniques. Atraumatic assessment of topical anaesthesia with a soft suction catheter or Yankauer sucker should be performed before ATI attempts.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar This has the added benefit of clearing any secretions or accumulated local anaesthetic before intubation. Antisialogogues reduce airway secretions, thereby improving airway anaesthesia and maximising the view achieved by a flexible bronchoscope. Options include the antimuscarinic agents glycopyrrolate, atropine or hyoscine. If used, glycopyrrolate 4 μg kg−1 i.m. should be given 40–60 min before performing ATI, for peak mucosal drying effect. The tachycardia associated with antimuscarinic agents may increase the patient's anxiety and hinder ATI, and their use is therefore not considered mandatory.3Leslie D Stacey M Awake Intubation.Contin Educ Anaesth Crit Care Pain. 2015; 15 (64–7)Abstract Full Text Full Text PDF Scopus (25) Google Scholar Awake intubation relies on the ability to secure a patient's airway and maintain spontaneous ventilation. Although awake intubation can be achieved using local anaesthesia alone, sedation reduces the patient's discomfort and improves cooperation during the procedure. However, the practitioner must exercise caution to avoid oversedation, which can cause airway obstruction, respiratory depression or cardiovascular instability, and result in significant morbidity or mortality.1Royal College of AnaesthetistsThe NAP4 report: major complications of airway management in the United Kingdom.2011Google Scholar A second anaesthetist responsible for managing drug injections should be present to avoid oversedation, and to reduce the cognitive load of the anaesthetist performing ATI.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar A number of agents are available for sedation and practice varies between practitioners. Remifentanil is a potent μ-opioid receptor agonist. It is rapidly hydrolysed by non-specific tissue and plasma esterases responsible for its rapid offset in action and therefore ease in titration. It is an analgesic and antitussive agent that can be used as the single sedative agent during ATI. It may be used alone in the rare cases where topicalisation is contraindicated. Recent guidelines advocate its use at effect site concentrations of 1.0–3.0 ng ml−1.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar It is associated with high rates of patients' satisfaction, but the incidence of recall is higher when remifentanil is used as the sole agent.17Johnston K.D. Rai M.R. Conscious sedation for awake fibreoptic intubation: a review of the literature.Can J Anaesth. 2013; 60: 584-599Crossref PubMed Scopus (69) Google Scholar Adverse effects of remifentanil relevant to ATI include: bradycardia, hypotension, apnoea, hypoxia and chest wall rigidity. If used as part of a multiagent regimen, the adverse effects of or oversedation by remifentanil may be reversed with naloxone or by titrating the infusion rate and taking advantage of its rapid offset of effect.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar Dexmedetomidine is an agent with α-adrenoreceptor agonist activity with a markedly increased affinity for α2 over α1-adrenoreceptors in comparison with clonidine. Effects upon α2-adrenoreceptors within the pons mediate its sedative effects, whereas action at spinal α2-adrenoreceptors produces analgesia. Its ability to produce sedation and analgesia without respiratory depression means it is becoming increasingly used for procedural sedation including ATI, although this is currently an unlicensed use in the UK. The cardiovascular effects of α2-agonists are an important consideration. Inhibition of noradrenaline (norepinephrine) release and bradycardia reduce cardiac output and result in hypotension.18Scott-Warren V.L. Sebastian J. Dexmedetomidine: its use in intensive care medicine and anaesthesia.BJA Educ. 2016; 16: 242-246Abstract Full Text Full Text PDF Scopus (42) Google Scholar Direct effects on vascular tissues after the injection of i.v. bolus doses may result in the development of transient hypertension, causing further reflex bradycardia.17Johnston K.D. Rai M.R. Conscious sedation for awake fibreoptic intubation: a review of the literature.Can J Anaesth. 2013; 60: 584-599Crossref PubMed Scopus (69) Google Scholar Doses are as follows: a loading dose 1 μg kg−1 given over 10–20 min followed by an infusion starting at 0.7 μg kg−1 h−1 and titrated to the desired clinical effect at between 0.2 and 1.0 μg kg−1 h−1.18Scott-Warren V.L. Sebastian J. Dexmedetomidine: its use in intensive care medicine and anaesthesia.BJA Educ. 2016; 16: 242-246Abstract Full Text Full Text PDF Scopus (42) Google Scholar At the time of writing, no target controlled infusion (TCI) model exists. The long duration of bolus dose required is potentially problematic when ATI needs to be performed urgently. Several agents have been used for procedural sedation or ATI, but negative features mean their use is not recommended. Boluses of midazolam increases the likelihood of oversedation and associated complications.3Leslie D Stacey M Awake Intubation.Contin Educ Anaesth Crit Care Pain. 2015; 15 (64–7)Abstract Full Text Full Text PDF Scopus (25) Google Scholar Ketamine has been studied, but intense coughing, agitation and the high rates of recall mean it is not recommended.17Johnston K.D. Rai M.R. Conscious sedation for awake fibreoptic intubation: a review of the literature.Can J Anaesth. 2013; 60: 584-599Crossref PubMed Scopus (69) Google Scholar Propofol boluses, simple infusion and TCI are widely used for sedation, but airway obstruction, coughing and high rates of oversedation mean propofol is not advised for ATI.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar The complications associated with tracheal intubation have been recently covered in this journal.19Wallace S. McGrath B.A. Laryngeal complications after tracheal intubation and tracheostomy.BJA Educ. 2021; 21: 250-257Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The most frequently encountered complications associated with ATI include: multiple attempts at intubation, desaturation and failed ATI.20Grange K. Mushambi M.C. Jaladi S. Athanassoglou V. Techniques and complications of awake fibre-optic intubation – a survey of Difficult Airway Society members.Trends Anaesth Crit Care. 2019; 28: 21-26Crossref Scopus (8) Google Scholar Other complications relate to the effects of instrumentation with a tracheal tube and include nasal bleeding and sore throat.21Woodall N.M. Harwood R.J. Barker G.L. Complications of awake fibreoptic intubation without sedation in 200 healthy anaesthetists attending a training course.Br J Anaesth. 2008; 100: 850-855Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar An unsuccessful attempt at ATI is defined as unplanned removal of the flexible bronchoscope, videolaryngoscope or tracheal tube from the airway.2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar Repeated unsuccessful attempts at ATI increase the likelihood of airway bleeding, obstruction and further difficulty. Experienced help should be sought early in any difficult ATI. It is vital to remember that effective sedation, oxygenation and topicalisation allow time to consider options in an awake, breathing patient. This important consideration is fundamental to the safety profile of ATI. Subsequent attempts at ATI should alter an element in order to increase the likelihood of successful ATI, for example switching from ATI:VL to ATI:FB. After a maximum of three unsuccessful attempts and a further one by a more experienced practitioner, the Difficult Airway Society algorithm for failed ATI should be followed, where potential options include postponement, ATI with front-of-neck access and high-risk general anaesthetic. Decision making should consider patient, surgical and equipment factors (Fig 3).2Ahmad I. El-Boghdadly K. Bhagrath R. et al.Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults.Anaesthesia. 2020; 75: 509-528Crossref PubMed Scopus (175) Google Scholar ATI remains an underused technique, even when indicated.1Royal College of AnaesthetistsThe NAP4 report: major complications of airway management in the United Kingdom.2011Google Scholar Although clinical opportunities may be limited, improved teaching and training can improve familiarity and expertise, particularly with flexible bronchoscopes. The ready availability of manikins and simulators can rapidly improve proficiency in flexible scope handling.22Marsland C. Larsen P. Segal R. et al.Proficient manipulation of fibreoptic bronchoscope to carina by novices on first clinical attempt after specialized bench practice.Br J Anaesth. 2010; 104: 375-381Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar A stepwise approach to bronchoscope intubation training has been described (Fig 4).3Leslie D Stacey M Awake Intubation.Contin Educ Anaesth Crit Care Pain. 2015; 15 (64–7)Abstract Full Text Full Text PDF Scopus (25) Google Scholar Proceeding from manikin training to asleep flexible bronchoscope intubations allows operators to gain an appreciation of the differences between manikins and patients, without the anxiety of intubating awake patients with continued learning of the motor skills required. Learners progress to ATI:FB where clinically indicated, but airway assessment predicts normal anatomy, for instance, in a patient with limited cervical spine range of movement. Subsequent exposure to increasingly abnormal airway anatomy increases expertise and problem-solving skills. Competence should be demonstrated at each stage before progression to the next and expertise in management of the difficult airway should be the final goal.23Gibbins M. Kelly F. Cook T.M. Airway management equipment and practice: time to optimise institutional, team, and personal preparedness.Br J Anaesth. 2020; 125: 221-224Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar The authors declare that they have no conflicts of interest. The associated MCQs (to support CME/CPD activity) will be accessible at www.bjaed.org/cme/home by subscribers to BJA Education. Jaiker Vora FRCA is a specialty trainee in the Welsh School of Anaesthesia. David Leslie BSc (Hons) FRCA is a consultant anaesthetist at the University Hospital of Wales in Cardiff. His interests include obstetric anaesthesia and difficult airway management. He is an examiner for the Royal College of Anaesthetists. Mark Stacey FRCA ILTHE MSc (Med Ed) is a consultant anaesthetist at the University Hospital of Wales in Cardiff. His interests include obstetric anaesthesia, difficult airway management and medical education. He is a coauthor of the 2019 DAS guidelines for awake tracheal intubation and a current council member of the Association of Anaesthetists." @default.
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