Awake tracheal intubation: a core skill we are quietly losing

What the papers say

This international survey, supported by the European Airway Management Society, asked anaesthetists in 102 countries how they use awake tracheal intubation (ATI) and what stops them using it more.

The headline is a paradox. Almost every respondent (96.5%) regarded ATI as a core skill for anaesthetists, and three quarters said they could perform it independently. Yet only one in five said most of their colleagues were skilled in it. Two thirds perform fewer than 10 ATIs a year. Since videolaryngoscopy became widespread, 41% reported that their use of ATI had decreased a lot, and 8% no longer perform it at all.

Only half were aware of any ATI guideline, and fewer than 40% said their department monitored ATI success or complications. Among those who lacked confidence, the main reasons were limited endoscopic skill and doubt about whether the technique works. Most respondents wanted more training.

The survey has prompted a useful debate. In the accompanying editorial, Hansel and Zdravkovic describe ATI as drifting into a "high-acuity, low-occurrence" cycle, in which less awareness leads to less exposure and less practice, as has happened with thoracic epidurals and percutaneous tracheostomy.² They caution that the reported decline is an "amplification of anecdote" rather than measured activity. They also note that we still cannot identify in advance which patients with predicted difficulty truly need an awake approach. In correspondence, Ward argues that where difficulty is predicted, awake should be the default where possible, and that awake videolaryngoscopy makes this achievable.³

What is useful

• It is the largest picture of ATI practice to date, across a wide range of countries, experience and settings.
• It names a real phenomenon: normalisation of deviance. A run of successful intubations after induction, in patients who met the criteria for an awake approach, can gradually create the belief that this approach is always safe.
• Its recommendations are sensible: guideline dissemination, simulation and hands-on training, and departmental monitoring of outcomes.

What needs caution

• The response rate is unknown and respondents were self-selected. The authors acknowledge that clinicians who use ATI were more likely to respond, so skill levels are probably overstated.
• The decline in ATI since videolaryngoscopy is what respondents perceived, not what was measured, and the survey offered no option to report an increase.
• Many questions were skipped, so the denominators vary widely.
• The question asking whether indications should be "re-evaluated" given videolaryngoscopy is somewhat leading, and does not say whether indications should be narrowed or broadened.
• Results are not reported by country, so there are no Australian figures.
• The survey describes practice. It does not link practice to patient outcomes.

My commentary

This paper is personal for me. In 2012, with colleagues from the ANZCA Airway Management Special Interest Group, I co-authored Topicalisation and Sedation for Awake Fibreoptic Intubation, a practical guide for experienced endoscopists and a teaching aid for trainees.⁴ We described awake fibreoptic intubation as an essential core component of the anaesthetic skill set. Fourteen years later, almost every respondent to this survey agrees. The problem is that agreeing a skill is essential is not the same as maintaining it.

Several of the survey's findings reflect exactly the issues we tried to address.

The first is how the skill is learned. Over 40% of respondents acquired it on sedated patients with normal airways. Our booklet advocated deliberate practice on dexterity manikins and asleep fibreoptic intubation, and learning one standardised technique well before branching out. As we put it, perfect practice makes perfect, not just practice. ANZCA's 2025 syllabus now requires a minimum of five awake intubations during training.² That is a welcome floor, but it is not a ceiling. A procedure performed fewer than 10 times a year cannot be maintained by clinical exposure alone.

The second is sedation. Remifentanil was the most common choice in the survey, which matches our view that it is probably the ideal first-line agent: titratable, reversible and, at appropriate targets, compatible with a cooperative patient. Yet 40% of respondents use midazolam. We wrote then, and I still believe, that the best anxiolytic is reassurance from a confident anaesthetist, not midazolam. Good topicalisation, a calm explanation and a second clinician managing sedation do more for the patient than a benzodiazepine. When an awake intubation goes badly, the cause is more often inadequate topicalisation or excessive sedation than the technique itself.

The third, and most important, is videolaryngoscopy. It has transformed airway management, and for many predicted difficult airways it is now the right first choice after induction. However, a videolaryngoscope is a device, not a strategy. The decision that matters is whether the patient should be awake or asleep when the airway is managed. That decision rests on whether oxygenation and rescue remain credible if the plan fails, which is the point Dr Rani Chahal makes in a recent editorial.⁵ Heidegger and Pandit go further, arguing that when difficulty is predicted, management should be tailored to reliably maintain oxygenation.⁶ Ward puts it well: the question is not only whether the patient can be intubated asleep, but how many attempts it takes, what harm it risks, and what happens if it fails.³

It is also worth remembering that videolaryngoscopy and awake intubation are not opposites. The Difficult Airway Society guidelines recognise videolaryngoscope-assisted ATI,⁷ and around 40% of respondents already use it. Ward argues that awake videolaryngoscopy should be actively encouraged, as a technique in its own right and as a stepping stone to other awake techniques.³ I agree. Our 2012 booklet was written around the flexible scope, but its principles of consent, preparation, topicalisation, sedation and oxygenation apply equally to awake videolaryngoscopy. If I were updating it now, I would include high-flow nasal oxygen and videolaryngoscope-assisted techniques. For many clinicians, a videolaryngoscope may be the easier route back to performing awake intubation when it is indicated.

Finally, the survey found that fewer than 40% of departments monitor their ATI outcomes. We cannot maintain a skill we do not measure. Departmental airway data, recording how often ATI is used, how often it succeeds and whether patients with documented predictors were managed awake or asleep, would tell us whether we are losing the skill, and whether that loss is harming patients. Hansel and Zdravkovic add a practical test: is there always someone on site, including after hours, who can perform an awake intubation?²

Awake intubation is not obsolete. It is a high-acuity, low-opportunity skill, and those skills are lost quietly unless we deliberately teach, practise and audit them.

References

1. Cortese G, Steinberg I, Brazzi L, et al. Awake tracheal intubation in the era of videolaryngoscopy: an international survey of 4728 clinicians. Anaesthesia 2026; 81: 1481–8. doi:10.1111/anae.70291
2. Hansel J, Zdravkovic M. Awake tracheal intubation as a high-acuity, low-occurrence event: is widespread videolaryngoscopy to blame? Anaesthesia 2026; 81: 1464–8. doi:10.1111/anae.70302
3. Ward PA. Awake tracheal intubation: the default technique? Anaesthesia 2026. doi:10.1111/anae.70429
4. Bradley P, Chapman G, Greenland K, Heard A, Hughes R, Mehra R, Segal R, Sivasubramaniam B, Tan H. Topicalisation and sedation for awake fibreoptic intubation. Melbourne: ANZCA Airway Management Special Interest Group, 2012. ANZCA (PDF)
5. Chahal R. Beyond difficult: matching airway risk to intervention. Anaesthesia 2026. doi:10.1111/anae.70455
6. Heidegger T, Pandit JJ. Difficult airway management: from the power of prediction to the art of management. Anesth Analg 2025; 140: 290–4. doi:10.1213/ANE.0000000000007202
7. Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2020; 75: 509–28. doi:10.1111/anae.14904

See also: Teaching & Education, where the topicalisation and sedation guide is listed as a teaching resource.

This commentary is my own professional opinion, written for anaesthetists and other professional readers. It does not represent Alfred Health, ANZCA or any other organisation with which I am associated, and it is not individual medical advice. The original articles are the work of their authors and are linked above.