Pharmacological approach to awake tracheal intubation

Purpose of review: This review synthesizes current evidence on pharmacological strategies for awake tracheal intubation (ATI), a cornerstone technique for anticipated difficult airways that remains underutilized despite guideline recommendations. Recent findings: Over 30 sedation regimens have been described, with no single protocol demonstrating clear superiority. Dexmedetomidine shows the most complete pharmacological profile, providing anxiolysis, antisialagogue effects, and cough suppression with minimal respiratory depression. Ultra-short-acting agents such as remifentanil and remimazolam enable precise titration via target-controlled infusion. Combination regimens reduce individual drug dosing and associated side effects. Lidocaine remains the gold standard for topicalization (maximum 9 mg/kg lean body weight), with various administration routes showing equivalent efficacy when properly applied. Emerging evidence supports videolaryngoscopy as an alternative to flexible bronchoscopy for selected cases. Summary: Successful ATI depends on adequate airway topicalization, judicious sedation maintaining spontaneous ventilation, and operator expertise. Any sedation regimen proves superior to none, but meticulous dose titration and monitoring are essential. Standardized training and institutional protocols remain critical for optimizing safety and utilization.