BJA Education, 22(8): 298e305 (2022)
doi: 10.1016/j.bjae.2022.03.006
Matrix codes: 1C01,
2A01, 3A01
Awake tracheal intubation
J. Vora1,*, D. Leslie2 and M. Stacey2
1
Welsh School of Anaesthesia, Cardiff, UK and 2Department of Anaesthetics, University Hospital of Wales,
Cardiff, UK
*Corresponding author. jaikervora@doctors.org.uk
Keywords: Airway Management; Anaesthesia; Intubation
Learning objectives
By reading this article, you should be able to:
 Explain the predictors of the difficult airway and
the techniques required for awake tracheal intu-
bation (ATI).
 Describe approaches to airway preparation,
oxygenation and sedation during awake airway
techniques.
 Outline the considerations of managing unsuc-
cessful ATI.
 Develop an approach to improved training and
familiarity with ATI.
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 manage-
ment of the anticipated difficult airway, because of its high
success rates and low risk profile. However, ATI accounts for
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 ob-
stetric 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.
Accepted: 15 March 2022
Crown Copyright © 2022 Published by Elsevier Ltd on behalf of British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: permissions@elsevier.com
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Advance Access Publication Date: 15 June 2022
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 pre-
dictors 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.
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.1 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.2 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.3 No single technique has been demonstrated to be
superior when both are possible, except in patients with
significantly limited mouth opening, tongue or neck defor-
mity. In these situations ATI:FB may be the preferred modal-
ity.3 A dual technique, called video-assisted flexible/fibreoptic
intubation (VAFI), requiring both a videolaryngoscope and a
bronchoscope has also become increasingly used.4 The term
ATI may also be expanded to include ATI with front-of-neck
298

airway and awake tracheostomy, but this article will focus
upon conventional intubation with a tracheal tube.2
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.5 In cases of recognised difficult laryn-
goscopy 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 contraindi-
cations include: allergy to local anaesthetic, airway bleeding
(where blood may obscure the image achieved through a
flexible bronchoscope or videolaryngoscope), the uncoopera-
tive patient and certain airway tumours (with the potential to
cause a ‘cork-in-bottle’ airway obstruction).3
ATI:FB
Fibreoptic intubation was first performed in the 1960s and
thereafter, bronchoscopes have become a mainstay of diffi-
cult 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.2 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 flex-
ible bronchoscope) and impingement on the larynx are po-
tential barriers to successful ATI:FB. Numerous tracheal
tubes can be used for ATI:FB; reinforced flexometallic, intu-
bating laryngeal mask airway (ILMA) and nasotracheal tubes
can all be used.3 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.
ATI:VL
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 manage-
ment technique as we enter the endemic phase of the
disease.6 Its advantages include technical familiarity with a
similar success rate and safety profile to ATI:FB.7 ATI:VL
does not affect time to intubation, when compared with
ATI:FB.8 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.2 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.2
VAFI
A number of case reports have described a technique using
both flexible bronchoscopy and videolaryngoscopy, in order
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Awake tracheal intubation
to achieve successful tracheal intubation in the awake pa-
tient where ATI:FB alone may have failed. It requires a
minimum of two experienced operators, the first using vid-
eolaryngoscopy 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.4,9e11
Preparation for the procedure
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.12
Recent guidelines support clinical experience that the oper-
atong theatre environment is the optimal location for per-
forming ATI.2 Association of Anaesthetists guidelines for
patients receiving sedation should be followed.13 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 check-
lists 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.14 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.3 Positioning the
patient in the semirecumbent position offers anatomical and
physiological advantages to performing ATI.2
Oxygenation
The indications and clinical scenarios where ATI is consid-
ered 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.15 Traditional nasal cannulae or an inverted
Hudson mask offer alternative options where HFNO is
unavailable.
Topical anaesthesia
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 prepa-
rations, including combination with vasoconstrictors (such as
adrenaline [epinephrine] and phenylephrine) which reduce
the likelihood of epistaxis when nasal intubation is preferred.2
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
BJA Education - Volume 22, Number 8, 2022 299
Awake tracheal intubation

Checklist for Awake Tracheal Intubation

1. Location
2. Appropriate staff present
Anaesthetic assistant Second anaesthetist
monitoring, sedation, anaesthesia
Other
3. Team briefed
Procedure outline Role allocation

Plan for failure

4. ATI device selected, prepared and checked
Tube (type/size)

Flexible bronchoscope Videolaryngoscope

Route Device/blade

Optional adjuncts Optional adjuncts

Oral airway Suction Stylet
Suction
SAD Mucosal atomiser
Bougie
Aintree catheter Epidural catheter Mucosal atomiser

Device check Device check

Focus Tube correctly loaded Lubricated
White balance Anti-fog/wiped
Image orientation
Lubricated Tube correctly loaded
Anti-fog/wiped Battery/power Battery/power

5. Oxygenation
6. Sedation (if required)
7. Topicalisation Maximum lidocaine dose
kg × 9 mg.kg–1 = mg
Nose Oropharynx Larynx Trachea Planned lidocaine dose
sprays of 10% mg
Vasoconstrictor (if required) Antisialogogue (if used) ml of 2% mg
ml of 4% mg
8. Setup position
Operator Patient Monitor Suction

Pumps Step Airway Trolley Bed

Fig 1 The DAS checklist for awake tracheal intubation in adults. SAD, supraglottic airway device.

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 Awake tracheal intubation

A B

,
TI XY IC
EN
C , O ET
O G
SU NE TH
H AES

N
ANAESTHETIC
MACHINE, OXYGEN,

AC N
M A

I
SUCTION
OPERATOR ASSISTANT
IT T
N N

VI NIT
R

M
O IE

D O
O

O
M AT

EO R

MONITOR
PATIENT
P

AI OL
TR
RW L
PATIENT PATIENT

AY Y
E
AI OL
PUMPS
OPERATOR TR
RW L
AY Y

M VID
O E
E

N
IT O
O
R
PUMPS ASSISTANT SECOND
ANAESTHETIST

SECOND
ANAESTHETIST

Fig 2 Suggested ergonomics for the performance of awake tracheal intubation. Alongside pictorial representation of the ergonomics and equipment required.

blocks to the superior laryngeal and glossopharyngeal
nerves.16 There is insufficient evidence to recommend a
single technique, but nerve blocks are associated with
increased plasma concentrations of local anaesthetic.2
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).
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 intuba-
tion or airway obstruction.
Adequate airway topical anaesthesia is vital to the success
of ATI techniques. Atraumatic assessment of topical anaes-
thesia with a soft suction catheter or Yankauer sucker should
be performed before ATI attempts.2 This has the added benefit
of clearing any secretions or accumulated local anaesthetic
before intubation.

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Awake tracheal intubation
Table 1 Authors’ technique for ATI. MAD, mucosal atomisation device; TCI target-controlled infusion; TT, tracheal tube.
Local anaesthetic technique
Nose Cophenylcaine (0.5 ml) via MAD to
each nostril
Pharynx Lidocaine 10% spray (10 mg per
spray)
 1 Spray to tip of tongue
 6 Sprays to base of each tonsillar
pillar
Larynx Lidocaine 2% via epidural catheter
inserted via suction port of scope.
 2 ml above vocal cords
 2 ml below vocal cords
Pass scope through cords
Pass TT through cords
(Alternative injection via MAD if
ATI:VL preferred)
Antisialogogues
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, glyco-
pyrrolate 4 mg kg 1 i.m. should be given 40e60 min before
performing ATI, for peak mucosal drying effect. The tachy-
cardia associated with antimuscarinic agents may increase
the patient’s anxiety and hinder ATI, and their use is therefore
not considered mandatory.3
Sedation
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 im-
proves 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.1 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.2 A number of agents are available for sedation and
practice varies between practitioners.
Remifentanil
Remifentanil is a potent m-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 contra-
indicated. Recent guidelines advocate its use at effect site
concentrations of 1.0e3.0 ng ml 1.2 It is associated with high
rates of patients’ satisfaction, but the incidence of recall is
higher when remifentanil is used as the sole agent.17 Adverse
effects of remifentanil relevant to ATI include: bradycardia,
hypotension, apnoea, hypoxia and chest wall rigidity. If used
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Sedation Instructions to patient Time
Second anaesthetist to manage 0 min
sedation
Remifentanil TCI
Start with low target concentration
(e.g. 0.5e1 ng ml 1)
Increase to maximum 3 ng ml 1
(0.5 ng ml 1 increments)
Deep breath 1
Deep breath 2
Deep breath 3
Deep breath 4
5 min
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.2
Dexmedetomidine
Dexmedetomidine is an agent with a-adrenoreceptor agonist
activity with a markedly increased affinity for a2 over a1-
adrenoreceptors in comparison with clonidine. Effects upon
a2-adrenoreceptors within the pons mediate its sedative ef-
fects, whereas action at spinal a2-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 a2-agonists are an important
consideration. Inhibition of noradrenaline (norepinephrine)
release and bradycardia reduce cardiac output and result in
hypotension.18 Direct effects on vascular tissues after the in-
jection of i.v. bolus doses may result in the development of
transient hypertension, causing further reflex bradycardia.17
Doses are as follows: a loading dose 1 mg kg 1 given over
10e20 min followed by an infusion starting at 0.7 mg kg 1 h 1
and titrated to the desired clinical effect at between 0.2 and 1.0
mg kg 1 h 1.18 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.
Other agents
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.3 Ketamine has been studied,
but intense coughing, agitation and the high rates of recall
mean it is not recommended.17 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.2
 Awake tracheal intubation

Management of unsuccessful ATI in adults

CALL FOR HELP

If life-threatening airway obstruction at any time proceed to emergency FONA

100% OXYGEN
STOP SEDATION 100% oxygen can be given via facemask,
P HFNO or SAD (if adequately topicaIised)
O
S Immediate airway management is
T STOP essential when:
P No AND • Airway patency is compromised
O THINK • Ventilation is compromised
Prepare for emergency FONA

N Is immediate airway • Neurology is compromised

E management • Urgent or immediate surgery is required
essential? • Expected clinical deterioration

Yes

Consider
• Patient factors - anatomy, compliance
• Skill availability - anaesthetist
ATI: FONA or surgeon competence
appropriate? • Equipment availabiIity

Yes No • Surgeon scrubbed

• Avoid gas induction
• Ensure neuromuscular blockade
Failed • Consider videolaryngoscopy first
ATI: FONA High-risk GA • All intubation attempts (awake or asleep)
by most experienced practitioner

Fig 3 DAS failed ATI algorithm. FONA, front-of-neck access; SAD, supraglottic airway device.

Complications of ATI. Subsequent attempts at ATI should alter an element in

order to increase the likelihood of successful ATI, for example
The complications associated with tracheal intubation have
switching from ATI:VL to ATI:FB. After a maximum of three
been recently covered in this journal.19 The most frequently
unsuccessful attempts and a further one by a more experi-
encountered complications associated with ATI include:
enced practitioner, the Difficult Airway Society algorithm for
multiple attempts at intubation, desaturation and failed ATI.20
failed ATI should be followed, where potential options include
Other complications relate to the effects of instrumentation
postponement, ATI with front-of-neck access and high-risk
with a tracheal tube and include nasal bleeding and sore
general anaesthetic. Decision making should consider pa-
throat.21
tient, surgical and equipment factors (Fig 3).2

Failed ATI Training

An unsuccessful attempt at ATI is defined as unplanned ATI remains an underused technique, even when indicated.1
removal of the flexible bronchoscope, videolaryngoscope or Although clinical opportunities may be limited, improved
tracheal tube from the airway.2 Repeated unsuccessful at- teaching and training can improve familiarity and expertise,
tempts at ATI increase the likelihood of airway bleeding, particularly with flexible bronchoscopes. The ready avail-
obstruction and further difficulty. Experienced help should be ability of manikins and simulators can rapidly improve pro-
sought early in any difficult ATI. It is vital to remember that ficiency in flexible scope handling.22 A stepwise approach to
effective sedation, oxygenation and topicalisation allow time bronchoscope intubation training has been described (Fig 4).3
to consider options in an awake, breathing patient. This Proceeding from manikin training to asleep flexible broncho-
important consideration is fundamental to the safety profile scope intubations allows operators to gain an appreciation of

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Awake tracheal intubation

Manikin training Low stress

Asleep fibreoptic intubation with

predicted normal anatomy

Awake fibreoptic intubation with

predicted normal anatomy

Awake fibreoptic intubation with

predicted abnormal anatomy High stress

Fig 4 A stepwise approach to ATI:FB training.

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 man-
agement of the difficult airway should be the final goal.23
Declaration of interests
The authors declare that they have no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
References
1. Royal College of Anaesthetists. The NAP4 report: major
complications of airway management in the United Kingdom.
2011. London
2. Ahmad I, El-Boghdadly K, Bhagrath R et al. Difficult
Airway Society guidelines for awake tracheal intubation
(ATI) in adults. Anaesthesia 2020; 75: 509e28
3. Leslie D, Stacey M. Awake Intubation. Contin Educ Anaesth
Crit Care Pain 2015; 15. 64e7
4. Saunders TG, Gibbins ML, Seller CA et al. Videolaryngoscope-
assisted flexible intubation tracheal tube exchange in a
patient with a difficult airway. Anaesth Rep 2019; 7: 22e5
5. Crawley SM, Dalton AJ. Predicting the difficult airway. BJA
Educ 2015; 15: 253e7
6. Cook TM, El-Boghdadly K, McGuire B et al. Consensus
guidelines for managing the airway in patients with
COVID-19. Anaesthesia 2020; 75: 785e99
7. Alhomary M, Ramadan E, Curran E, Walsh SR. Video-
laryngoscopy vs. fibreoptic bronchoscopy for awake
tracheal intubation: a systematic review and meta-anal-
ysis. Anaesthesia 2018; 73: 1151e61
8. Rosenstock CV, Thøgersen B, Afshari A, Christensen AL,
Eriksen C, Gatke MR. Awake fibreoptic or awake video
laryngoscopic tracheal intubation in patients with antic-
ipated difficult airway managementda randomized clin-
ical trial. Anesthesiology 2012; 116: 1210e63
9. Go mez-Rı́os MA,  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:
411e2
10. Chung MY, Park B, Seo J, Kim CJ. Successful airway
management with combined use of McGrath® MAC video
laryngoscope and fiberoptic bronchoscope in a severe
obese patient with huge goiter e a case report. Korean J
Anaesth 2018; 71: 232e6
11. Liew GHC, Wong TGL, 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: 117e20
12. Miller T, Miller T, McCann A, Stacey M, Groom P. Cogni-
tive psychology, the multidisciplinary operating theatre
team, and managing a cannot intubate, cannot oxygenate
emergency. Br J Anaesth 2020; 125: e12ee15
13. Association of Anaesthetists of Great Britain and Ireland.
Recommendations for standards of monitoring during
anaesthesia and recovery. Anaesthesia 2016; 71: 85e93
14. Davis M, Hignett S, Hillier S, Hames N, Hodder S. Safer
anaesthetic rooms: human factors/ergonomics analysis
of work practices. J Perioper Pract 2016; 26: 274e80
15. El-Boghdadly K, Onwochei DN, Cuddihy J et al.
A prospective cohort study of awake fibreoptic intubation
practice at a tertiary centre. Anaesthesia 2017; 72: 694e703
16. Sudheer P, Stacey MR. Anaesthesia for awake intubation.
BJA CEPD Rev 2003; 3: 120e3
17. Johnston KD, Rai MR. Conscious sedation for awake
fibreoptic intubation: a review of the literature. Can J
Anaesth 2013; 60: 584e99
18. Scott-Warren VL, Sebastian J. Dexmedetomidine: its use
in intensive care medicine and anaesthesia. BJA Educ
2016; 16: 242e6
19. Wallace S, McGrath BA. Laryngeal complications after
tracheal intubation and tracheostomy. BJA Educ 2021; 21:
250e7
20. Grange K, Mushambi MC, Jaladi S, Athanassoglou V.
Techniques and complications of awake fibre-optic intu-
bation e a survey of Difficult Airway Society members.
Trends Anaesth Crit Care 2019; 28: 21e6

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 Awake tracheal intubation

21. Woodall NM, Harwood RJ, Barker GL. Complications of
awake fibreoptic intubation without sedation in 200
healthy anaesthetists attending a training course. Br J
Anaesth 2008; 100: 850e5
22. Marsland C, Larsen P, Segal R et al. Proficient manipula-
tion of fibreoptic bronchoscope to carina by novices on
first clinical attempt after specialized bench practice. Br J
Anaesth 2010; 104: 375e81
23. Gibbins M, Kelly F, Cook TM. Airway management
equipment and practice: time to optimise institutional,
team, and personal preparedness. Br J Anaesth 2020; 125:
221e4

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