Awake Tracheal Intubation (ATI) in Adults

Publication Date: November 1, 2019
Last Updated: March 14, 2022
  1. Awake tracheal intubation must be considered in the presence of predictors of difficult airway management.
  2. A cognitive aid such as a checklist is recommended before and during performance of awake tracheal intubation.
  3. Supplemental oxygen should always be administered during awake tracheal intubation.
  4. Effective topicalisation must be established and tested. The maximum dose of lidocaine should not exceed 9−1 lean body weight.
  5. Cautious use of minimal sedation can be beneficial. This should ideally be administered by an independent practitioner. Sedation should not be used as a substitute for inadequate airway topicalisation.
  6. The number of attempts should be limited to three, with one further attempt by a more experienced operator (3 + 1).
  7. Anaesthesia should only be induced after a two-point check (visual confirmation and capnography) has confirmed correct tracheal tube position.
  8. All departments should support anaesthetists to attain competency and maintain skills in awake tracheal intubation.


Recommendation Grading



Awake Tracheal Intubation (ATI) in Adults

Authoring Organization

Endorsing Organization

Publication Month/Year

November 1, 2019

Last Updated Month/Year

January 31, 2024

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Social worker, physician, nurse, nurse practitioner, physician assistant


Management, Treatment

Diseases/Conditions (MeSH)

D007442 - Intubation, Intratracheal, D014691 - Ventilation


Awake tracheal intubation, tracheal tube, facemask ventilation, supraglottic airway device, SAD, ventilation, tracheal intubation, FONA, flexible bronchoscopy, videolaryngoscopy

Supplemental Methodology Resources

Data Supplement, Data Supplement, Data Supplement