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Counselling for awake intubation after a previous failed intubationActor: 41-year-old woman, BMI 42, booked for elective laparoscopic cholecystectomy

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Awake intubation: high success and good safety; fails in 1–2%, rarely needing rescue.
  • sTOP: sedation (optional), topicalisation, oxygenation, performance.
  • Topical lidocaine limit: 9 mg/kg of lean body weight; oxygen throughout.
  • Remifentanil TCI 1–3 ng/mL; avoid boluses.
  • Three attempts plus one by a more experienced operator; induce only after the two-point check.

The patient

Actor: 41-year-old woman, BMI 42, booked for elective laparoscopic cholecystectomy. A letter from another hospital records a failed intubation; she was woken and surgery abandoned. She is anxious and asks to be asleep before anything is done. Task: explain and gain consent for awake tracheal intubation.

The examiner asks

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  1. Open

    How do you start?

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    • I'm meeting a woman with a past failed intubation before her gallbladder surgery, to plan an awake intubation. Patient
    • Can you tell me what happened last time, and what you remember? Communication
    • That sounds frightening. Thank you for bringing the letter; it helps keep you safe.

  2. Explain

    Explain what you recommend and what she will feel.

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    • Because the tube was so hard to place before, the safest way is while you're awake. (Communication)
    • You keep breathing for yourself throughout, so you're never left unable to breathe.
    • We numb your nose and throat with sprays, and give a little sedation to relax you.
    • A thin camera guides the tube through your nose. You'll feel pressure, maybe a cough.
    • Oxygen runs the whole time. Once we see the tube is right, we put you to sleep.
    • It works in about 98 or 99 out of 100 people.

  3. Respond

    She says: 'Last time was awful. Please just put me to sleep.'

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    • I understand you don't want to be awake for any of it after last time. (Communication)
    • Putting you to sleep first could leave us unable to get oxygen in. That's the danger.
    • Staying awake keeps you breathing, and that is exactly what makes this safe.

  4. Respond

    She asks: 'And what if it doesn't work?'

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    • We stop after a few tries, with a senior colleague making the last one. (Communication)
    • You'd still be breathing, so we can stop safely while you're awake.
    • Then we'd postpone, or use a neck airway under local anaesthetic; we'd agree that beforehand.

  5. Close

    How do you close?

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    • Shall we go ahead awake? You can ask questions or stop at any point. Communication
    • If you'd rather not, we postpone and talk again. We won't proceed against your wishes.
    • I'll document this discussion and your consent.
    • Afterwards she gets an airway alert letter, and her record is flagged. After surgery

Fatal mistakes

  • Agreeing to induction and a relaxant before securing the airway.
  • Hiding the backup plan.
  • Proceeding after she refuses.

Checked against: Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults (2020)

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