Awake tracheal intubation as a high-acuity, low-occurrence event: is widespread videolaryngoscopy to blame?

Abstract

Awake tracheal intubation, defined as the placement of a tracheal tube in an awake, spontaneously breathing patient, either by means of a flexible bronchoscope and/or videolaryngoscope, is a risk-mitigation strategy in patients with predicted features of difficult airway management [1]. Numerous guidelines endorsed by professional societies advocate for awake tracheal intubation in the context of predicted difficulty [2-4] and the Difficult Airway Society (DAS) has published dedicated guidelines on the topic [1].

Cortese et al. conducted an international survey of 4728 clinicians from 102 countries, assessing contemporary practice patterns and perceptions surrounding awake tracheal intubation in the era of widespread videolaryngoscopy [5]. The survey follows similar recent projects conducted at national level [6, 7], providing an important international perspective on practice of awake tracheal intubation. A few themes and ongoing questions relating to training curricula, indications and standardisation of awake tracheal intubation emerge, which we explore in more detail.

Awake tracheal intubation was perceived as a core skill for any anaesthetist by 97% of survey respondents [5]. However, depending on regional factors, such as patient case-mix, procedural delegation and availability of alternate approaches, the procedure can move quickly into the category of ‘high acuity, low occurrence’ events for some, akin to emergency front-of-neck airway situations (Fig. 1). Indeed, only 76% of respondents reported performing awake tracheal intubation clinically, leaving a skill gap for a number of anaesthetists. The gap is likely larger, as ‘performing awake tracheal intubation clinically’ does not equal ‘performing awake tracheal intubation with sufficient frequency to maintain proficiency’. Similar trends have been observed for other anaesthesia and critical care techniques, with thoracic epidurals and percutaneous tracheostomies serving as comparable examples [8, 9]. These procedures have in some settings led to subspecialisation, where only a handful of clinicians in a given department perform them with sufficient frequency to maintain competence. Were such an approach taken with awake tracheal intubation, there are obvious ramifications to both individual clinician skill retention and overall service provision. Emergency awake tracheal intubation becomes even more relevant outside of regular working hours when skilled staff may not be available to deliver the appropriate intervention.

International curricula for postgraduate training in anaesthesia variably refer to awake tracheal intubation as a core skill. In the UK, the 2021 curriculum of the Royal College of Anaesthetists expects a fully qualified anaesthetist to be able to perform fibreoptic tracheal intubation independently, with further key capabilities including performing awake tracheal intubation in patients with advanced airway pathology [10]. Similarly, the 2025 syllabus of the Australian and New Zealand College of Anaesthetists makes multiple references to awake tracheal intubation, with a set minimum number of five procedures [11]. The American Board of Anesthesiology specifies fibreoptic bronchoscopy as a basic anaesthesia topic [12], although no number of procedures or level of knowledge domain acquisition is specified.

The landscape in European curricula is much more heterogeneous. The European Training Requirement published in 2018 made no reference to awake tracheal intubation [13]. However, the updated version published in 2022 included “appropriate selection of awake and asleep fibreoptic intubation” among airway management clinical skills [14]. The 2021 competency-based training in Intensive Care Medicine in Europe syllabus makes the expectation of being able to perform fibreoptic laryngoscopy under supervision explicit, with a specific breakdown of knowledge, skill and attitude learning items [15]. Other global regions may exhibit further heterogeneity, with specific competencies being institution- or training programme-dependent. A notable exception in South Asia is the specification of the Medical Council of India for an independent anaesthetist to be able to topicalise the airway for an awake procedure and perform a fibreoptic tracheal intubation [16].

These regional differences may reflect downstream variations in the primary allocation of awake tracheal intubation. In countries or systems where the national, regional or local standard is for head and neck surgeons to perform awake tracheal intubation (as stated by 11% of respondents in the survey by Cortese et al.), this will inevitably lead to fewer such procedures being performed by anaesthetists [5]. Such situations may represent blind spots for postgraduate learning systems, and educators need to make deliberate efforts to ensure all anaesthesia residents receive sufficient opportunities to develop the skills required for safe provision of awake tracheal intubation. This might foreseeably account for some of the gaps seen in the survey by Cortese et al., even though respondents estimate that 90% of these procedures are in fact performed by anaesthetists. For appropriate service provision, arrangements should be made that ensure there is at least one appropriately skilled anaesthetist on site able to perform awake tracheal intubation at any given time. This is perhaps most consistently achieved if awake tracheal intubation remains (or becomes) a core skill for all anaesthetists.

Two additional findings stand out in the survey report from Cortese et al. First, fewer than half of respondents (48%) appear to be aware of any existing guidelines for awake tracheal intubation [1]. The survey does not offer an exploration of potential reasons, yet it is easy enough to imagine that the global reach of DAS guidelines, particularly relating to awake tracheal intubation, is limited. Second, 69% of anaesthetists believed that the frequency of awake tracheal intubation has decreased, either slightly (28%) or a lot (41%), after the widespread implementation of videolaryngoscopy. It is important to caveat these estimates as amplifications of anecdote (“I feel we do X less often…”), rather than observable rates of activity. One limitation of the survey tool used is that it did not offer the response option that the frequency of awake tracheal intubation had actually increased after widespread implementation of videolaryngoscopy; it is entirely plausible that for some respondents this might have been the case. Furthermore, whereas rates of awake tracheal intubation may indeed have decreased over time, along with more widespread videolaryngoscopy use, it is difficult to infer causality. Nevertheless, it remains a considerable proportion; the notion that more videolaryngoscopy (i.e. easier and more successful asleep tracheal intubations) results in fewer cases needing to be done awake has some face validity.

This tension is presented in Fig. 2. Although a considerable proportion of patients may be predicted to have a ‘difficult’ airway, many can still be managed successfully with videolaryngoscopy (or flexible bronchoscopy or both) under general anaesthesia. In hindsight, only a subset of patients undergoing awake tracheal intubation may have been uniquely dependent on an awake approach for safe airway management. Having said that, if tracheal tube placement is successful, the patient has benefitted from awake tracheal intubation.

There are also some disadvantages of awake tracheal intubation: fear (patient and physician); hypertension; discomfort; coughing; gagging; feeling of demise; and agitation. However, one of the most devastating complications of tracheal intubation overall remains the inability to oxygenate the patient, and avoidance of awake tracheal intubation in this case may have disastrous consequences. The schematic in Fig. 2 does not endorse any practice, that is, an increase or decrease in the use of awake techniques; it merely illustrates the need for better diagnostics and approaches to risk-stratifying patients [6]. Blended approaches, such as awake diagnostic videolaryngoscopy followed by either asleep or awake tracheal intubation based on the findings need further investigation. Despite the lack of robust evidence on awake airway visualisation, this approach is also recommended in the 2025 DAS guidelines [2].

Similar to routine videolaryngoscopy yielding the highest benefits when used regularly, competence and confidence in performing awake tracheal intubation is difficult to maintain without regular exposure and practice. Sustaining these skills requires support from individual clinicians and healthcare systems, through approaches such as simulation, mental rehearsal and skill acquisition during clinical practice [17, 18].

At the same time, the need for routine training and exposure needs to be balanced against judicious use of a procedure and avoidance of indication creep. Is lowering the indication threshold for performing awake tracheal intubation for educational purposes justifiable? Vague indications without external benchmarking may result in variation in practice. This is compounded when guidelines, often developed by experts working in highly specialised centres with limited stakeholder engagement, extrapolate from a context removed from the intended destination. Whereas a centre dealing with a large volume of complex head and neck cases may consider awake tracheal intubation as almost routine, most hospitals with a more varied case-mix are unlikely to share that view. There, anaesthetists need to pay even more attention to skill fade and mitigating avoidance, to avoid exacerbating the vicious cycle, as presented in Fig. 1.

Clearly, uncertainties remain. Looking at the DAS 2020 awake tracheal intubation and 2025 unanticipated difficult airway guidelines, it is not immediately clear what exactly the indications are for awake tracheal intubation [1, 2]. The survey by Cortese et al. reinforces this notion, as 83% of respondents chose a combination of anatomical and physiological factors as the trigger for choosing awake tracheal intubation, rather than any given number of predictors of difficulty. Revisiting the 2020 DAS guidelines, the advice is that awake tracheal intubation “must be considered” in the presence of difficult airway predictors. There exists, however, a subset of cases where asleep videolaryngoscopy alone would have sufficed. This is reflected in 78% of survey respondents indicating that indications should be reconsidered due to the more widespread use of videolaryngoscopy. This is reasonable in principle. The difficulty, however, is that we still lack accurate bedside tests and tools for predicting which patients belong to that subset [19]. Therefore, in the absence of such knowledge – and this is arguably something that should be high on the research agenda – we rely on expert opinion and various manifestations of clinical gestalt, a diagnostic approach where healthcare professionals use pattern recognition, experience and holistic perception to make rapid, appropriate decisions, particularly in emergency settings.

The issue is that even expert opinion is prone to ample subjectivity and may result in disparate approaches to achieve the same clinical goal. A well-known survey of eight international airway management experts on how to undertake anaesthesia for a complex patient with a retrosternal thyroid mass showed that there is considerable variation in decisions on management [20]. Perhaps unsurprisingly, none of them agreed on every single aspect of care. Although this study is now possibly considered outdated, we would argue the uncertainty, and with it the variation in practice and approach, persists.

We can perhaps at least take solace in our jobs being safe from the rise of artificial intelligence, which relies on verifiable data that can be benchmarked to be most efficacious [21]. However, it may serve as a renewed reminder that anaesthesia still lags behind many other medical specialities in the routine delivery of large-scale randomised controlled trials addressing clinically important questions [22, 23]. Another observable problem with surveys in our field, is a decline in overall reach; where we have had over 10,000 respondents in 2019–2020 [24, 25], this has now fallen to around 3500–5000 [5, 26]. While appreciating the underlying heterogeneity, we should also seek ways to best deliver evidence-based care, which is at least based on standardised approaches to some extent. The addition of a new core outcome set for airway management research, among other efforts, may serve as a small stepping stone to advance standardisation in airway management [27].

Taken together, some of the signals identified in the survey by Cortese et al. may represent an early indicator of potential danger. Awake tracheal intubation continues to have an important role in modern airway management and remains a core skill for all independently practicing anaesthetists. However, without robust indications, clear curricular embedding and continued clinical exposure, it is at risk of being extinguished, at worst, or relegated to a few chosen experts, at best. We will then need to consider how to bridge the gap between work as imagined and work as done, in the interest of patient safety. This may represent an opportunity for the speciality.