Scope and Framing This review examines the indications for awake tracheal intubation (ATI) in the context of modern videolaryngoscopy (VL), synthesizing guidance from the Difficult Airway Society (DAS), the American Society of Anesthesiologists (ASA), the Canadian Airway Focus Group (CAFG), and emerging decision-making tools. It covers both adult and pediatric populations, addresses whether VL has shifted the…
THE EVIDENCE
What each source contributes, and how strong it is
Study design first — a cohort and a randomised trial do not carry the same weight.
Design
Year
Journal
What it found
Guideline
2025
BMC anesthesiology
Guidelines on awake tracheal intubation agree on the procedure itself and on
Cohort
2015
Canadian journal of anaesthesia =
Awake intubation was used in about 1% of general anaesthetics and that rate did not
Meta-analysis
2022
British journal of anaesthesia
Videolaryngoscopy likely reduces rates of failed intubation compared to direct
Cohort
2016
Anesthesiology
Awake intubation took a median of 24 minutes from entering theatre against 16
Meta-analysis
2024
Journal of clinical medicine
For awake tracheal intubation, videolaryngoscopy shortened intubation time compared
Meta-analysis
2021
British journal of anaesthesia
Optical stylets result in the shortest time to tracheal intubation compared to
6 resolved citations behind this deck; every point above traces to one of them.
WHERE THE GUIDANCE SITS
What the guidelines and pooled evidence say
4 findings, each on the slide that follows.
BMC anesthesiology 2025
Guidelines on awake tracheal intubation agree on the procedure itself and on
Guidelines on awake tracheal intubation agree on the procedure itself and on confirming tube position
British journal of anaesthesia 2022
Videolaryngoscopy likely reduces rates of failed intubation compared to direct
Videolaryngoscopy likely reduces rates of failed intubation compared to direct laryngoscopy (Macintosh-style RR=0.41, hyperangulated RR=0.51,…
Journal of clinical medicine 2024
For awake tracheal intubation, videolaryngoscopy shortened intubation time compared
For awake tracheal intubation, videolaryngoscopy shortened intubation time compared with flexible bronchoscopy and slightly reduced desaturation…
British journal of anaesthesia 2021
Optical stylets result in the shortest time to tracheal intubation compared to
Optical stylets result in the shortest time to tracheal intubation compared to flexible bronchoscopes and videolaryngoscopes during awake tracheal…
WHERE THE GUIDANCE SITS
Guidelines on awake tracheal intubation agree on the procedure itself and on
Guideline · BMC anesthesiology
Guidelines on awake tracheal intubation agree on the procedure itself and on confirming tube position, but conflict on indications and airway local anaesthesia, and only 3 of 7 were rated high quality.
Guideline Recommendations on the Assessment and Management of Awake Airway Intubation: A Systematic Review, BMC anesthesiology 2025 · PMID 39966725
WHERE THE GUIDANCE SITS
Videolaryngoscopy likely reduces rates of failed intubation compared to direct
Meta-analysis · British journal of anaesthesia
Videolaryngoscopy likely reduces rates of failed intubation compared to direct laryngoscopy (Macintosh-style RR=0.41, hyperangulated RR=0.51, channelled RR=0.43).
Videolaryngoscopy Versus Direct Laryngoscopy for Adults Undergoing Tracheal Intubation: A Cochrane Systematic Review and Meta-Analysis Update, British journal of anaesthesia 2022 · PMID 35820934
WHERE THE GUIDANCE SITS
For awake tracheal intubation, videolaryngoscopy shortened intubation time compared
Meta-analysis · Journal of clinical medicine
For awake tracheal intubation, videolaryngoscopy shortened intubation time compared with flexible bronchoscopy and slightly reduced desaturation below 90%, with no difference in failure or first-attempt success.
Videolaryngoscopy Versus Fiberoptic Bronchoscopy for Awake Tracheal Intubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Journal of clinical medicine 2024 · PMID 38892899
THE NUMBERS
Videolaryngoscopy is faster for awake intubation
11 trials, 873 patients, versus flexible bronchoscopy.
Shorter intubation time and slightly less desaturation, with no difference in failure or first-attempt success.
Videolaryngoscopy Versus Fiberoptic Bronchoscopy for Awake Tracheal Intubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Journal of clinical medicine 2024 · PMID 38892899
WHERE THE GUIDANCE SITS
Optical stylets result in the shortest time to tracheal intubation compared to
Meta-analysis · British journal of anaesthesia
Optical stylets result in the shortest time to tracheal intubation compared to flexible bronchoscopes and videolaryngoscopes during awake tracheal intubation.
Airway Devices for Awake Tracheal Intubation in Adults: A Systematic Review and Network Meta-Analysis, British journal of anaesthesia 2021 · PMID 34303493
IN PRACTICE
What the cohorts and reviews add
2 findings, each on the slide that follows.
Awake intubation was used in about 1% of general anaesthetics and that rate did not
Awake intubation was used in about 1% of general anaesthetics and that rate did not fall over 12 years despite a large rise in videolaryngoscopy,…
Anesthesiology 2016
Awake intubation took a median of 24 minutes from entering theatre against 16
Awake intubation took a median of 24 minutes from entering theatre against 16 minutes for intubation after induction, with a 1% failure rate and 1.6%…
IN PRACTICE
Awake intubation was used in about 1% of general anaesthetics and that rate did not
Cohort · Canadian journal of anaesthesia =
Awake intubation was used in about 1% of general anaesthetics and that rate did not fall over 12 years despite a large rise in videolaryngoscopy, with 2% of attempts failing.
The Incidence, Success Rate, and Complications of Awake Tracheal Intubation in 1,554 Patients Over 12 years: An Historical Cohort Study, Canadian journal of anaesthesia = Journal canadien d'anesthesie 2015 · PMID 25907462
IN PRACTICE
Awake intubation took a median of 24 minutes from entering theatre against 16
Cohort · Anesthesiology
Awake intubation took a median of 24 minutes from entering theatre against 16 minutes for intubation after induction, with a 1% failure rate and 1.6% complications — it costs time, not safety.
A Retrospective Study of Success, Failure, and Time Needed to Perform Awake Intubation, Anesthesiology 2016 · PMID 27111535
THE NUMBERS
Awake intubation adds about eight minutes
Median time from entering theatre to intubation, 1,085 awake cases vs 2,170 matched controls.
Failure was 1% and complications 1.6% among the awake cases; the study did not measure those outcomes in the comparison group, so this is a statement about time, not relative safety.
A Retrospective Study of Success, Failure, and Time Needed to Perform Awake Intubation, Anesthesiology 2016 · PMID 27111535
THE NUMBERS
Use halved even as the airway got easier
692 awake intubations, 2014 to 2020, and first-attempt success by device.
Frequency fell by half over seven years; where it is still done, the bronchoscope outperforms the videolaryngoscope.
INDICATIONS
When this is the right block
DAS guidelines for awake tracheal intubation in adults, Anaesthesia 2020
Anticipated difficult airway management
The Difficult Airway Society's guidelines open by stating that awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management, and are written explicitly to lower the threshold for performing it when indicated.
Prospective cohort of awake fibreoptic intubation practice, Anaesthesia 2017
The airways that actually get it
In a prospective cohort of 600 awake fibreoptic intubations at a tertiary centre, the commonest indication was reduced mouth opening (26.8%), followed by previous airway surgery and previous head and neck radiotherapy (22.5% each), with most cases presenting for head and neck surgery. The overall failure rate was 1.0%.
Declining incidence of awake tracheal intubation, Can J Anaesth 2023
Decide for it before the case becomes an emergency
In a seven-year single-centre cohort of 692 cases, awake tracheal intubation use fell by about 50% between 2014 and 2020. Whether that costs patients is unclear, but it certainly costs training opportunities and maintenance of competence — which is a reason to choose it deliberately, not by default.
CONTRAINDICATIONS
When it is not
DAS guidelines for awake tracheal intubation in adults, Anaesthesia 2020
Starting without a stated plan for failure
Management of unsuccessful awake tracheal intubation is one of the key areas for which the Difficult Airway Society made specific recommendations, alongside indications, setup, checklists, oxygenation, topicalisation, sedation and verification of tube position. An awake technique that has no declared next step is not a plan.
Prospective cohort of awake fibreoptic intubation practice, Anaesthesia 2017
An operator early on the learning curve without supervision
In the 600-case cohort, 11.0% of awake fibreoptic intubations were complicated — most often by multiple attempts (4.2%), over-sedation (2.2%) or desaturation (1.5%) — and the only significant association with complications was the number of previous awake intubations the operator had performed. Trainees were primary operator in 78.6% of cases, 86.8% of those directly supervised by a consultant.
Declining incidence of awake tracheal intubation, Can J Anaesth 2023
Reaching for the videolaryngoscope as the awake device by default
In a 692-case cohort, first-attempt success was significantly higher with flexible bronchoscopy than with videolaryngoscopy for awake intubation (84% versus 60%), while oral and nasal routes were identical at 82%. The route is a free choice; the device is not.
PEARLS
What experience adds
Prospective cohort of awake fibreoptic intubation practice, Anaesthesia 2017
Oxygen through the nose for the whole procedure
In the 600-case cohort, oxygenation was delivered by high-flow, heated and humidified nasal oxygen in 49.0% of awake fibreoptic intubations, and the commonest sedative technique was combined target-controlled infusions of remifentanil and propofol.
DAS guidelines for awake tracheal intubation in adults, Anaesthesia 2020
Four elements, in that order
The Difficult Airway Society breaks the procedure into sedation, topicalisation, oxygenation and performance, and suggests that treating them as four separate practical problems helps practitioners plan, perform and address complications.
Brief the room and the patient in the same sentence
Before the first spray of local, say aloud who holds the scope, who watches the saturation, who pushes the sedation, and what the patient will feel next. Everyone including the patient should hear the same plan once, calmly, rather than three versions of it under pressure.
IN THE ROOM
What this changes about the next case
Colour is the strength of the evidence behind each step, not the urgency.
1
1
Guidelines on awake tracheal intubation agree on the procedure itself and on confirming tube position, but conflict on indications and airway local anaesthesia, and only 3 of 7 were rated high quality.
2
2
Videolaryngoscopy likely reduces rates of failed intubation compared to direct laryngoscopy (Macintosh-style RR=0.41, hyperangulated RR=0.51, channelled RR=0.43).
3
3
For awake tracheal intubation, videolaryngoscopy shortened intubation time compared with flexible bronchoscopy and slightly reduced desaturation below 90%, with no difference in failure or first-attempt success.
4
4
Optical stylets result in the shortest time to tracheal intubation compared to flexible bronchoscopes and videolaryngoscopes during awake tracheal intubation.
5
5
Awake intubation was used in about 1% of general anaesthetics and that rate did not fall over 12 years despite a large rise in videolaryngoscopy, with 2% of attempts failing.
The oral-boards stem on the next slide puts these into one scenario.
KEY TAKEAWAYS
What to carry into the next case
Guidelines on awake tracheal intubation agree on the procedure itself and on
BMC anesthesiology 2025
Awake intubation was used in about 1% of general anaesthetics and that rate did not
Videolaryngoscopy likely reduces rates of failed intubation compared to direct
British journal of anaesthesia 2022
Awake intubation took a median of 24 minutes from entering theatre against 16
Anesthesiology 2016
Guidelines on awake tracheal intubation agree on the procedure itself and on
Questions I'll ask you in the room
How would you teach this to a CA-1 in two minutes?
Where does the evidence for this actually stop?
What would you do differently in a resource-limited setting?
Defend the alternative you decided against.
Oral boards stem
A 55-year-old with a supraglottic tumour, stridor when supine, and previous neck radiation presents for panendoscopy. Mouth opening is 3 cm. The resident proposes inhalational induction with a videolaryngoscope ready.
Board questions
1. Among the airway devices compared in a network meta-analysis of awake tracheal intubation in adults — flexible bronchoscopes, videolaryngoscopes and optical stylets — which device gave the shortest time to tracheal intubation?
Show answer
Optical stylets resulted in the shortest time to tracheal intubation compared with flexible bronchoscopes and videolaryngoscopes during awake tracheal intubation.
The network meta-analysis ranks optical stylets fastest for awake intubation — speed is the outcome that separated the devices here.
Airway Devices for Awake Tracheal Intubation in Adults: A Systematic Review and Network Meta-Analysis, British journal of anaesthesia 2021 · PMID 34303493
2. A colleague argues against awake tracheal intubation in an anticipated difficult airway on the grounds that it takes too long and is risky. Using the retrospective data on time, failure and complications for awake intubation versus intubation after induction, what is the actual cost of choosing awake intubation?
Show answer
The cost is time, not safety. Awake intubation took a median of 24 minutes from entering theatre versus 16 minutes for intubation after induction, with a 1% failure rate and 1.6% complications.
Roughly eight extra minutes is the real price of an awake intubation, and that is a cheap thing to spend on an airway you are worried about.
A Retrospective Study of Success, Failure, and Time Needed to Perform Awake Intubation, Anesthesiology 2016 · PMID 27111535
3. You are choosing between a videolaryngoscope and a flexible bronchoscope for an awake tracheal intubation. Based on the pooled randomised trials comparing these two approaches, which outcomes favour videolaryngoscopy and which outcomes showed no difference?
Show answer
Videolaryngoscopy shortened intubation time compared with flexible bronchoscopy and slightly reduced desaturation below 90%. There was no difference in failure rate or in first-attempt success.
Videolaryngoscopy for an awake intubation buys you speed and a little less desaturation, not a better chance of getting the tube in.
Videolaryngoscopy Versus Fiberoptic Bronchoscopy for Awake Tracheal Intubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Journal of clinical medicine 2024 · PMID 38892899
The bottom lineGuidelines on awake tracheal intubation agree on the procedure itself and on
Sources
[1] Guideline Recommendations on the Assessment and Management of Awake Airway Intubation: A Systematic Review, BMC anesthesiology 2025 · PMID 39966725 open
[2] The Incidence, Success Rate, and Complications of Awake Tracheal Intubation in 1,554 Patients Over 12 years: An Historical Cohort Study, Canadian journal of anaesthesia = Journal canadien d'anesthesie 2015 · PMID 25907462 open
[3] Videolaryngoscopy Versus Direct Laryngoscopy for Adults Undergoing Tracheal Intubation: A Cochrane Systematic Review and Meta-Analysis Update, British journal of anaesthesia 2022 · PMID 35820934 open
[4] A Retrospective Study of Success, Failure, and Time Needed to Perform Awake Intubation, Anesthesiology 2016 · PMID 27111535 open
[5] Videolaryngoscopy Versus Fiberoptic Bronchoscopy for Awake Tracheal Intubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Journal of clinical medicine 2024 · PMID 38892899 open
[6] Airway Devices for Awake Tracheal Intubation in Adults: A Systematic Review and Network Meta-Analysis, British journal of anaesthesia 2021 · PMID 34303493 open
[7] DAS guidelines for awake tracheal intubation in adults, Anaesthesia 2020 · PMID 31729018 open
[8] Prospective cohort of awake fibreoptic intubation practice, Anaesthesia 2017 · PMID 28654138 open
[9] Declining incidence of awake tracheal intubation, Can J Anaesth 2023 · PMID 36289151 open