An awake intubation video laryngoscopy technique gives clinicians a safe way to secure a predicted difficult airway while the patient keeps breathing on their own. For years, awake tracheal intubation (ATI) meant flexible bronchoscopy. Today, video laryngoscopy offers a practical alternative in many cases. This guide explains when clinicians choose awake intubation, how the procedure works, and what the evidence says about video laryngoscopy compared with a flexible scope.
This article is educational and does not replace local protocols or supervised training.
What awake tracheal intubation is
Awake tracheal intubation means placing a tracheal tube while the patient remains conscious and breathing spontaneously. Topical anesthesia numbs the airway, and light sedation may help comfort.
The main advantage is safety. Because the patient keeps their own airway tone and breathing, the team avoids the cannot intubate, cannot oxygenate scenario that can follow induction of anesthesia.
The Difficult Airway Society guidelines for awake tracheal intubation, published in Anaesthesia in 2020, set out a structured approach. In addition, the ASA 2022 practice guidelines include awake intubation as an option for predicted difficult airways. See our summary of the ASA guidelines for video laryngoscopy.
When awake intubation is indicated
Clinicians consider ATI when they predict difficulty with both intubation and rescue oxygenation. Common situations include:
- Head and neck tumors or previous radiotherapy that limit tissue movement.
- Limited mouth opening or restricted neck movement.
- Airway obstruction, such as swelling or infection in the upper airway.
- Severe obesity combined with other predictors of difficulty.
- Unstable cervical spine where neck movement must be minimal.
- Previous failed intubation with a documented difficult airway.
ATI is not suitable for every patient. For example, it may not work in uncooperative patients, in some children, or when there is a true emergency with no time to prepare.
Why choose an awake intubation video laryngoscope approach
Flexible bronchoscopy remains the most flexible tool for ATI. It can pass through the nose, navigate distorted anatomy, and work in very limited mouth opening.
However, video laryngoscopy has practical strengths:
- Many clinicians use video laryngoscopes every day, so the technique feels familiar.
- Setup is fast, with no scope to prepare or clean between steps.
- The wider view helps orientation when secretions are present.
- Everyone in the room can see the screen and follow the procedure.
The evidence supports these benefits. A 2018 meta-analysis in Therapeutics and Clinical Risk Management found similar success rates for video laryngoscopy and fiberoptic bronchoscopy, with a risk ratio of 1.00. Meanwhile, intubation took about 40.4 seconds less with video laryngoscopy.
A 2024 meta-analysis in the Journal of Clinical Medicine reached a similar conclusion. Video laryngoscopy showed shorter intubation time and a lower risk of oxygen saturation falling below 90%.
Still, the two tools complement each other. In practice, many experienced teams combine them, using the video laryngoscope to open the airway and a flexible scope to guide the tube.
Choosing between a flexible scope and an awake intubation video laryngoscope
The right tool depends on the patient, the anatomy, and the team. A simple way to decide is to look at access, speed, and experience.
Mouth opening. A video laryngoscope needs enough mouth opening for the blade. If opening is very limited, a nasal flexible scope is usually the better choice.
Anatomy. Distorted anatomy from tumors or radiotherapy can make a blade view difficult. In these cases, a flexible scope can follow the airway around obstacles.
Speed. When the airway is accessible, an awake intubation video laryngoscope approach is often quicker. For this reason, it suits patients who tire easily or struggle to cooperate for long.
Experience. Teams should use the technique they perform best. Because many clinicians use video laryngoscopes daily, the learning curve is often shorter.
Backup. Whichever tool comes first, the other should be ready. In addition, the team should agree on a plan if the awake attempt fails, including a surgical airway when needed.
Preparing for an awake intubation video laryngoscope procedure
Preparation decides success. The DAS guidelines use the sTOP framework, which stands for sedation, topicalization, oxygenation, and performance.
Sedation
Sedation is optional. When used, it should be light, so the patient stays cooperative and keeps breathing. Over-sedation removes the main safety benefit of ATI.
Topicalization
Topical anesthesia is the most important element. Clinicians usually apply lidocaine to the tongue, oropharynx, and larynx, often with sprays, gels, or nebulizers. The DAS guidelines advise that total topical lidocaine should not exceed 9 mg/kg lean body weight.
Before inserting the device, the operator should test topicalization gently. If the patient still gags, the team adds more local anesthesia before proceeding.
Oxygenation
DAS recommends high-flow nasal oxygen throughout the procedure. As a result, the team gains time and reduces the risk of desaturation.
Performance
The operator and assistant should agree on roles, the plan, and the stopping point. DAS advises limiting attempts, with a more experienced operator taking over if early attempts fail.
Performing awake intubation with a video laryngoscope
Once the airway is numb, the steps follow a calm and steady sequence.
- Sit the patient upright or semi-upright if possible, which helps breathing and comfort.
- Explain each step to the patient before it happens.
- Insert the blade slowly in the midline, letting the patient adjust.
- Find the epiglottis and the glottis on screen with minimal force.
- Pass the tube, ideally loaded on a bougie or guided through a channeled blade.
- Confirm placement with waveform capnography before giving induction drugs.
- Induce anesthesia only after confirmation, then secure the tube.
A channeled hyperangulated blade can help here. Because the channel guides the tube toward the glottis, the operator can focus on keeping a steady view.
Gentle technique matters throughout. Too much force can trigger coughing or gagging, even with good topical anesthesia.
Common problems and how teams handle them
Gagging or coughing. This usually signals incomplete topicalization. Pause, add local anesthesia and try again.
Secretions on the lens. Suction before insertion helps. Some teams also give an antisialagogue in advance to reduce secretions.
Tube hits the arytenoids. Rotating the tube or withdrawing the blade slightly often helps it pass.
Patient distress. Stop, reassure the patient, and reassess the plan. If needed, switch operator or technique.
Training for awake intubation video laryngoscope skills
Teams perform ATI less often than routine intubation, so skill decay is a real concern. The DAS guidelines encourage regular training, including practice in elective cases where ATI is suitable.
Video recording supports this. When the monitor records the procedure, trainers can review technique and topicalization with the team afterwards. Our guide to video capture for airway management training explains how. For blade selection, see our article on hyperangulated vs Macintosh blades for difficult airways.
How Astra-vue supports awake intubation
Astra-vue offers blades suited to ATI on one monitor platform. Reusable Ultra Blades include a channeled hyperangulated design, a standard hyperangulated blade, and Macintosh sizes 1 to 4. For single-use workflows, the Pro Blade and the Lite Blade are available, with the Lite Blade offering an anti-fog coating.
The Mini Monitor has a 4 inch touchscreen and a 720p HD camera, records video to 16GB of storage and offers mini HDMI output for teaching displays. The system is FDA registered and listed, CE marked under MDR, and built under ISO 13485. Explore the range on our products page or contact our team.
Awake intubation video laryngoscope FAQs
Can you do an awake intubation with a video laryngoscope?
Yes. Awake videolaryngoscopy is an established technique. Meta-analyses show similar success to flexible bronchoscopy, with shorter intubation times.
Is video laryngoscopy better than fiberoptic for awake intubation?
Neither is better in every case. Video laryngoscopy is often faster, while a flexible scope works better with very limited mouth opening or nasal routes.
Does the patient need sedation for awake intubation?
Not always. Sedation is optional and, when used, should be light. Good topical anesthesia matters more.
What is the sTOP approach?
It is the DAS framework for awake tracheal intubation. It stands for sedation, topicalization, oxygenation and performance.
When should induction drugs be given after awake intubation?
Only after the team confirms tube placement with waveform capnography. Giving drugs earlier removes the safety margin that ATI provides.
