Intubation is the process of inserting a tube through the mouth or nose and into the airway to assist with breathing. This is often done in emergency situations or when a patient cannot breathe adequately on their own. A common question that arises is whether patients are awake during this process. The short answer is that most patients are given sedation medication to make them unconscious for intubation. However, there are some exceptions where patients may be awake. In this article, we will explore the details around consciousness and sedation during intubation.
Are patients typically awake during intubation?
The majority of intubations are done with the patient in an unconscious state. Patients are given medication intravenously to sedate them and make them unaware during the intubation process. Commonly used sedation medications include propofol, etomidate, midazolam, and ketamine. These medications act quickly to induce a deep sleep-like state with loss of consciousness within 1-2 minutes. The medications also have amnesic properties, meaning the patient is unlikely to remember the experience.
Being awake during intubation can be unpleasant and traumatic for the patient. The tube has to pass through vocal cords and stimulate the gag reflex, which is uncomfortable. Coughing or gagging on the tube makes placement more difficult for the physician. In an emergency, quick placement and ventilation take priority over comfort. So sedation is used in most situations to facilitate the process and avoid an awful experience for the patient.
When could a patient potentially be awake?
There are some cases where patients may not receive full sedation and remain partially or fully awake during intubation:
– Need for neurologic assessment: For patients with brain injuries or stroke, doctors may avoid heavy sedation so that they can assess the neurological function and consciousness level. Light sedation is used but the patient may still respond and remember some of the procedure.
– Cardiac arrest: When patients are in sudden cardiac arrest, there is no time to administer sedation. CPR is initiated and the airway needs to be secured urgently. The patient is unconscious due to the cardiac arrest so sedation is not needed.
– Rapid sequence intubation (RSI): This technique is used when patients have a full stomach that increases the risk of vomiting and aspiration during intubation. Sedatives are usually avoided and paralytic agents given first to relax the muscles and make intubation easier. The patient is not able to move during this but may still be somewhat aware.
– Difficult airway access: Anatomical challenges or trauma injuries that make airway access difficult may necessitate an awake technique. Sedation cannot be safely given if the airway is not secured so local anesthetic is applied to numb the airway while the patient remains conscious.
What medications are used to sedate patients for intubation?
There are several types of sedative medications that can be used alone or in combination to achieve optimal sedation in preparation for intubation:
Medication | Mechanism | Onset | Comments |
---|---|---|---|
Propofol | GABA agonist | 30-60 seconds | Quick onset but can cause drops in blood pressure |
Etomidate | GABA agonist | 1 minute | Minimal effect on hemodynamics |
Midazolam | Benzodiazepine | 1-5 minutes | Amnesia,can be reversed with flumazenil |
Ketamine | NMDA antagonist | 1-2 minutes | Preserves respiratory drive and blood pressure |
Propofol and etomidate are commonly used for their rapid onset of sedation and unconsciousness. Midazolam has amnesic properties that make the patient unlikely to have memories of the event. Ketamine is useful for maintaining stable oxygenation and hemodynamics. Combinations like etomidate and midazolam or ketamine with propofol allow the benefits of each medication.muscle relaxant medications like rocuronium or succinylcholine may also be given to facilitate intubation and prevent gagging.
What level of sedation is optimal for intubation?
The optimal level of sedation for intubation is deep sedation approaching general anesthesia. This means the patient is in a coma-like unconscious state without response to stimuli. Assessment scales like the Ramsay scale or Riker sedation scale are used to gauge the sedation depth. A score of 5-6 on these scales represents a perfect level for safe intubation.
Light sedation is not enough as patients may still have a gag reflex, cough on the tube or attempt to grab it. Moderate sedation leaves the possibility the patient could wake up during the procedure and remember it later which can be psychologically traumatic. The medications used for intubation induction are designed to produce deep sedation reliably within 1-2 minutes. This gives the physicians sufficient time to visualize the vocal cords and smoothly pass the endotracheal tube.
General anesthesia with complete loss of consciousness is not required for intubation. It does further diminish reflexes but at the cost of more cardiovascular depression. Rapid intubation with just deep sedation is preferable over prolonging the induction process. The sedation depth can be increased after the airway is secured if needed.
What are the risks of being awake during intubation?
Being awake and conscious when the endotracheal tube is inserted has several risks and disadvantages:
– Severe discomfort and pain – Passing the tube is highly stimulating and unpleasant without sedation. Patients may experience pain, choking sensation, panic which can be traumatic.
– Combativeness – Fear and discomfort may cause some conscious patients to resist and fight the intubation. This can make tube placement very challenging.
– Vomiting and aspiration – The gag reflex is stimulated which can lead to vomiting during intubation. Stomach contents can then be aspirated into the lungs causing pneumonia.
– Intubation trauma – Any movement or combativeness while awake can result in trauma to the mouth and airway structures. Teeth may be dislodged or soft tissues damaged.
– Psychologic trauma – Being awake through the procedure can be psychologically scarring for some patients. Memories of choking or distress may lead to anxiety or post-traumatic stress disorder.
– Sympathetic stimulation – Being conscious during intubation leads to marked stimulation of the sympathetic nervous system. This causes hypertension, tachycardia and myocardial ischemia which can be detrimental.
– Prolonged procedure – Intubation takes longer in a combative or distressed awake patient prolonging the hypoxemia before the airway is secured. This risks brain injury from low oxygen.
These adverse effects underscore the importance of adequate sedation and unconsciousness for intubation whenever possible. An awake approach should only be used when absolutely necessary and with local anesthesia of the airway.
What are the indications for awake intubation?
There are limited situations when an awake intubation technique may be favored over deep sedation:
– Anticipated difficult airway on exam – Facial trauma, large tongue or limited neck mobility that indicates difficulty visualizing the cords or passing the tube.
– Unstable cervical spine – Avoiding sedation and paralysis lets the patient protect their neck during positioning. Local anesthetic to the airway can be done.
– Massive facial/mouth trauma – Avoiding sedation allows the patient to control bleeding and swelling by positioning or holding dressings in place during intubation.
– Full stomach/risk for aspiration – Being awake lowers risk of vomiting during the procedure in patients who recently ate.
– Need for neurologic monitoring – Neuro checks during the procedure may be required for acute brain issues.
– Adverse reactions to sedatives – Some patients may be allergic or intolerant to anesthetic medications.
The risks of an awake technique must be weighed against the anticipated benefits in each individual clinical scenario. Most anesthesiologists favor deep sedation for intubation in the majority of cases.
What are some techniques to reduce discomfort during awake intubation?
If an awake approach is chosen, there are ways to make the patient more comfortable and improve intubation conditions:
– Topical local anesthetics – Local nerve blocks of the airway and liberal application of lidocaine spray to numb all sensation.
– Lubricating the tube – Lubricant jelly on the tube reduces stimulation and makes passage easier through the vocal cords.
– Smaller tube size – Using a smaller diameter tube is less stimulating than larger tubes in the airway.
– Avoiding restraints – Unrestrained positioning allows the patient to follow commands and facilitate tube placement.
– Anxiolytics – Small doses of benzodiazepines like midazolam may take the edge off anxiety while keeping the patient awake.
– Mindful technique – Explaining each step and proceeding carefully reduces fear and discomfort reactions.
– Adequate pre-oxygenation – Maximize oxygen levels going into the procedure to allow more time for intubation without desaturating.
Despite these measures, there is no way to fully eliminate the extreme discomfort of passing a tube through the airway while conscious. This underscores the preference for adequate sedation in most scenarios.
Conclusion
The vast majority of endotracheal intubations are performed under deep sedation or general anesthesia to avoid trauma and discomfort. However, in select cases, an awake technique may be required if airway difficulty or hemodynamic instability are present. This necessitates mindful measures to moderate the pain and psychologic stress as much as possible. When feasible, sedation is still the preferred approach. The risks versus benefits of each technique must be weighed thoughtfully based on the clinical context. With care to tailor the approach, safe airway management can be achieved in both awake and fully sedated patients requiring intubation.