A Primer on Awake Intubation 

• When should you perform an awake intubation? The difficult airway that is not crashing! (angioedema, large neck mass.. Use your judgement)
• Steps to prepare:

1. Gather your normal routine intubation gear: DL, VL or bronchooscope, endotracheal tube, suction, BVM, monitor,
2. Be prepared for anything: IV fluids, push dose pressors, backups (bougie, LMA, etc.)
3. Prepare the patient: Tell the patient what is about to happen. Patients may get startled being awake and so much happening to them.
4. Dry them out: Consider glycopyrrolate 0.2mg IV or just taking gauze and drying out the mouth.
5. Numb them: Use nebulized 1% preservative free lidocaine in conjunction with 4% topical lidocaine to spray the pharynx and if possible spray the cords. 
6. Sedate them: Ketamine is great in this setting. Patient’s who are hypotensive can receive a lower dose (0.5-1mg/kg) and still have the same effect! If you don’t want/like ketamine, benzodiazepines also work!
7. Pre-oxygenate: High flow nasal cannula with non-rebreather!
8. Intubate them: For awake intubations, fiberoptic intubation is preferred. With a pre-leaded ET tube on the scope, pass the scope over the tongue and inferior to visualize the cords. Pass through the vocal cords and down to just above the carina. Pass the ET tube over the scope and secure the ET tube in place. 

 This is not very hard to do, but it requires a litle bit more set than RSI...but for the patient who  needs to keep their respiratory drive, this can be a life saver!