How unconscious does a patient need to be, to be intubated without drugs? In 76 comatose patients (Glasgow coma score [GCS] < or = 8) who were treated consecutively in an emergency department, the integrity of the cough reflex was not related to GCS. All comatose patients must be treated as if their airway is compromised but even at the lowest coma scores, there are many patients whose airway reflexes are sufficiently intact to make procedures such as endotracheal intubation difficult and dangerous without drugs. The state of the airway should be assessed independently of conscious level.