Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

TLDR

Awake tracheal intubation has a high success rate and favourable safety profile yet remains underused in anticipated difficult airway cases, despite various effective techniques being available. These guidelines provide comprehensive support for decision‑making, preparation, and practical performance of awake tracheal intubation, aiming to lower the threshold for its use when indicated. The guidelines were developed through a systematic review of all available evidence on awake tracheal intubation, supplemented by expert consensus and a Delphi study where evidence was limited, and provide recommendations on indications, procedural setup, checklists, oxygenation, airway topicalisation, sedation, tube‑position verification, complications, failure management, post‑intubation care, consent, and training. The guidelines suggest that structuring awake tracheal intubation around sedation, topicalisation, oxygenation, and performance elements can aid clinicians in planning, executing, and managing complications.

Abstract

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.