Tracheal intubation is a fundamental skill in airway management and there are several techniques used to achieve this. Classically, the use of a laryngoscope has been used for intubation of the airway by allowing direct visualisation of the glottis. A range of laryngoscopes exist with differences in their blades and sizes with the Macintosh blade the most frequently used. Other laryngoscopes discussed include the Miller and McCoy. Videolaryngoscopes consist of a high-resolution camera at the tip of the blade to allow for indirect visualisation of the glottis. Similarly, the range of shapes and sizes is vast. The use of videolaryngoscopes has introduced the ‘shared screen’ principle allowing others to also have a view during intubation and this can aid training and teaching. Awake tracheal intubation can be performed using flexible scopes or videolaryngoscopes and is recommended for anticipated difficult airway cases. Confirmation of tracheal tube placement is critical and should be performed in every case using capnography. Clinical signs may be unreliable and additional uses of flexible scopes and ultrasound may also be used.

Awake intubation is underused and relevant whenever difficult airway is predicted. Evidence suggests that awake videolaryngoscope-guided intubation is faster with equivalent success rate, safety profile and patient acceptance compared with flexible optical bronchoscope (FOB)-guided intubation. For successful awake intubation four elements are essential: continuous oxygenation, topicalisation, equipment handling skills and sedation. Thorough preparation is vital for the success of the procedure. This includes availability of relevant personnel, appropriate equipment, chosen method of oxygen delivery, and local anaesthetic and sedative drugs. The authors’ preferred position for awake FOB-guided intubation is face-to-face, and for awake videolaryngoscope-guided intubation the deckchair head-end position. Lidocaine is the most used local anaesthetic, applied using a variety of techniques. Meticulous and dose-appropriate application of local anaesthetic is crucial for success. Procedural sedation may be used to enhance your technique following a very careful patient evaluation for the suitability of sedation. Evidence supports using dexmedetomidine or remifentanil in order to create a situation where the patient is cooperative, oriented and tranquil. If possible, one anaesthetist with the sole responsibility of administering sedation and patient monitoring should be present during the procedure. Tracheal extubation of a patient who has been intubated awake should be planned after careful overall risk assessment of the safety of the procedure.