Awake intubation

Introduction The incidence of difficult airway is higher in patients undergoing ENT surgery and, specifically, in patients undergoing ENT cancer surgery [1]. Airway management of the patient with a known or predicted difficult airway undergoing ENT surgery requires a thorough preoperative evaluation, a discussion with the ENT surgeon regarding the patient’s airway and surgery-specific issues, and a detailed plan of action. The American Society of Anesthesiologists (ASA) formed a Task Force on Difficult Airway Management in 1992, and sought to establish a "difficult airway algorithm" to facilitate the management of the difficult airway and reduce the likelihood of adverse outcomes [2]. In this algorithm, which was updated in 2002, one of the primary management choices for the anesthesiologist is the decision of whether or not to perform awake intubation or attempt intubation after induction of general anesthesia [2,3]. The ASA algorithm stresses the concept that formulation of a strategy for intubation should include the feasibility of three basic options: awake intubation vs. intubation after induction of general anesthesia, noninvasive vs. invasive (surgical) techniques, and preservation vs. ablation of spontaneous ventilation [7]. It is well-accepted that the safest method for a patient who requires endotracheal intubation and has a difficult airway is for that patient to undergo awake intubation for the following reasons [2-8]. Patency of the airway is maintained through upper pharyngeal muscle tone. Spontaneous ventilation is maintained. A patient who is awake and well topicalized is easier to intubate, as the larynx moves to a more anterior position after induction of anesthesia, as compared to while awake. The patient can still protect his or her airway from aspiration. The patient is able to monitor his or her own neurologic symptoms to guard against disruption of the integrity of their own neurologic system (for example, the patient with cervical spine pathology).