Advanced Airway Management
Free.
Evidence-based.
Designed for real clinical practice.
lidocaine for the awake intubation.
a practical guide to efficient topicalization, lidocaine dosing & the importance of timing.
Most failed awake intubations are not caused by poor bronchoscopy skills.
They are not caused by inadequate sedation.
They occur because the airway is no longer adequately anesthetized when the bronchoscope finally reaches it.
Dense topical anesthesia typically provides only a 10–20 minute window of optimal conditions. Every unnecessary delay shrinks that window
timing and why this matters.
Successful awake intubation depends less on bronchoscopy skill or sedation than many clinicians realize. Most poorly tolerated awake intubations occur because providers fail to recognize one fundamental principle:
Dense topical airway anesthesia is short-lived.
(Typically 10–20 minutes in most patients.)
When airway topicalization is performed correctly, the result is a dense, well-anesthetized airway that allows comfortable instrumentation. However, this window is finite. Delays during topicalization, equipment preparation, or bronchoscopy allow airway sensation to gradually return, often leaving anesthesia patchy or incomplete by the time instrumentation begins.
The result of recovering airway sensation becomes additional lidocaine administration, escalating sedation, or a now uncomfortable patient "white-knuckling" through a vital procedure. Importantly, even though the original topical effect has already begun to wane, repeat lidocaine dosing is additive to plasma concentrations which - with a plasma elimination half-life of approximately 90–120 minutes - persist long after recovery of sensation within the airway.
The airway block was likely more than adequate—you were simply too slow to use it.
fight the time crunch.
Use glycopyrrolate pretreatment. You'll nearly double that window of dense mucosal numbing.
lidocaine dosing.
how much lidocaine is too much?
Honestly, no one knows really knows.
Traditional maximum doses (4.5–5 mg/kg without epinephrine and 7 mg/kg with epinephrine) were developed for infiltration and peripheral nerve blocks, not airway topicalization.
Depending on which professional society guideline is consulted, published recommendations for airway topicalization range from:
-
4–5 mg/kg
-
8.2 mg/kg
-
9.0 mg/kg
The true maximum safe topical airway dose remains unknown and varies based on the patient and other factors.
* Note that the weight-based dosing is based on lean body weight.
lidocaine dosing.
Typically, an adequately anesthetized airway can be achieved well below the maximum dosage recommendations. However, the ceiling should always be precalculated prior to each procedure and becomes especially relevant when repeat lidocaine dosing becomes necessary.
site of application in the airway affects absorption.
Lidocaine absorption progressively increases with administration deeper into the airway.
Systemic absorption is increased with:
Deeper airway sites
Method of delivery
Surface area exposed (lower airways have higher SA)
Increased vascularity
Infection of impaired mucosal integrity
Lack of glycopyrrolate pretreatment
200 mg applied to the tongue and posterior pharynx is not equivalent to 200 mg repeatedly delivered into the tracheobronchial tree.
fight the time crunch.
Use glycopyrrolate pretreatment. You'll nearly double that window of dense mucosal numbing.
lidocaine plasma levels outlast airway
topicalization effects.
As airway sensation returns, the plasma lidocaine concentration remains elevated long after.
The need for repeated dosing and LAST risk can be avoided entirely by time awareness and efficiency.
topicalization should only begin.
1) after adequate time is allowed for glycopyrrolate's drying effects
2) after all equipment (topicalization applicators, bronchoscope, ETT, defogger, lubricant, suction, monitors placed, patient positioned in OR, nasal cannula placed, etc) is entirely prepared.
Pearls & Pitfalls
01
The most common cause of a poorly tolerated awake intubation is inadequate airway anesthesia—not inadequate sedation.
02
Glycopyrrolate is one of the most useful adjuncts in awake intubation.
03
The airway regains meaningful sensation within 10-20 minutes while plasma lidocaine concentrations remain elevated or continue to rise.
04
Start topicalization only after all equipment is ready.