awake fiberoptic regimen

[heathermed]

would anyone please like to share their awake fiber optic intubation regimens?
I'm unfortunately having some trouble with this.
My biggest current issue is that the patient gags and coughs violently once I get past the cords, but any general advice would also be helpful.
I would prefer to avoid transtracheal block.

thank you!!!!

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[Mman]

glycopyrrolate
dexmeditomidine bolus up to 1 mcg/kg as long as HR/BP tolerate it
ketamine 0.5 mg/kg to 1 mg/kg bolus

nasal airway with lidocaine jelly to dilate nares
2% lidocaine 3 ml with atomizer extension tubing through the nasal tube while they inhale to anesthetize the cords and proximal trachea (I think it's called LMA MADgic)
once the tube is through the cords, propofol until they stop coughing (if they are coughing)

 

[Noyac]

Why do you want to avoid the transtracheal injection?

 

[scudrunner]

Glyco 0.6mg, possibly another 0.4 if not bone dry in 15 min. At 20 min, 6cc nebulized 4% lido. Back to OR. Hook up remi, start at 0.05mcg/kg/min. Check gag with magic wand, spray 4% lido in back of throat with wand 1-2x. When no gag, insert oral airway, name escapes me at the moment. Begin fiberoptic with lido syringe connected to epidural catheter loaded into port, hover above cords and spray. Advance through cords. Identify carina, slide tube down fiberoptic scope and withdrawal.

Topicalization is key. Drying oral secretions is key to topicalization.

Dexmedetomidine sedation works great too, instead of remi, just have to load during the nebulization.

 

[bcat85]

Glyco 0.6mg, possibly another 0.4 if not bone dry in 15 min. At 20 min, 6cc nebulized 4% lido. Back to OR. Hook up remi, start at 0.05mcg/kg/min. Check gag with magic wand, spray 4% lido in back of throat with wand 1-2x. When no gag, insert oral airway, name escapes me at the moment. Begin fiberoptic with lido syringe connected to epidural catheter loaded into port, hover above cords and spray. Advance through cords. Identify carina, slide tube down fiberoptic scope and withdrawal.

Topicalization is key. Drying oral secretions is key to topicalization.

Dexmedetomidine sedation works great too, instead of remi, just have to load during the nebulization.

I really like the opioid-only sedation. It seems to effectively blunt the cough reflex and I think that its probably the key to an effective AFOI (along with decent topicalization). I do use the transtracheal injection. It's safe and really helps with topicalization below the cords. Here's my typical regimen:

1. 3cc of 4% lidocaine atomized in preop.
2. 3cc of viscous 4% lidocaine in the OR gargled.
3. Transtracheal injection with 3cc 4% lidocaine.
4. Ovassapian airway
5. Fentanyl
6. Intubate (I tend to prefer a parker tube--it seems to slide off of the scope a bit easier).

 

[cockblockandrun]

1. Glyco
2. Versed
3. 4% lidocaine soaked in gauze. Then I wrap it around my Jackson Krauss right angle forceps and insert it into each side of the mouth for 1-2 minutes. The patient will cough a bit and gag for a few seconds- and I want this to ensure I've covered the entire superior laryngeal nerve. After this I can shove anything into the patient's mouth and there is no gagging or discomfort from the patient. The key is to make sure the gauze is dripping with 4% lidocaine. I don't use nebulizers, aerosolizers, etc. because there is no guarantee you are getting adequate SLN coverage.

 

[cockblockandrun]

http://www.alimed.com/jackson-laryngeal-forceps.html

You can buy one here.

 

[deleted59964]

glyco 0.4
co-phenylcaine to nose
remifentanil at 0.05 - 0.1 mcg/kg/min
devilbiss atomiser - spray enough in mouth that patient wants to spit it out, get them to gargle first.

 

[Ignatius J]

Ketamine titrated to nystagmus then a "little more". Ideally, not responsive to voice (I know, I know- "awake"). You can get a face tent or plastic 02 FM with a cut-out hole for the scope to give extra O2.

Go in with the scope, spray cords x 2 with 4% lidocaine. Go through.

We did rotations at a burn hospital in residency and this became almost second nature. You can give fentanyl a couple minutes before ketamine if you want to balance out the sympathetic effects of ketamine.

Haven't left this recipe in private practice because I just haven't seen anything both as simple and as effective as this approach. I've probably done this 100 times now.

 

[urge]

We did rotations at a burn hospital in residency and this became almost second nature.

Aren't all these patients trach'ed?

 

[urge]

2 of versed.

Toxic dose of lidocaine via scope as you go in.

Patience.

 

[Ignatius J]

Aren't all these patients trach'ed?

Negative.

 

[geogil]

Glyco 0.2-0.4 depending on tolerance for tachycardia, maybe more.
Fent sedation
Viscous 4% on tongue blade, applied liberally to oropharynx, have pt swirl around
Atomized 4% (non viscous obviously), try to have the pt inhale as they are doing this so that some gets into the trachea. progressively move the atomizer further back until you can touch the posterior pharynx without gag. I then turn the atomizer nozzle downards and spray the cords, which makes the pt cough, which is fine becuase they are inhaling more lido.
Finally, before intubation, get an LTA, put a nice bend in it, and slide it along the lateral aspect of the tongue until you get the piriform recess, numb that up too.
If possible, have an assistant hold the tongue, then gently insert FOB from the front, get the view, slide tube off.
I don't inflate the cuff right away because I have found that this often makes the pt cough even more, but wait until they are getting sleepy to do it.

 

[Ezekiel2517]

Glyco
Atomizer 4% lido. I get a bottle of phenylephrine nasal spray, dump most of it, fill it with 4% lido, spray nose. Nasal airways with lido jelly.
Remi at 0.1 once in the room
If doing nasal awake, place ETT in nose like you're doing nasal intubation, and place the scope thru it leading right to the cords.

 

[Noyac]

If you ask 10 anesthesiologists this question you will get 10 different answers. As you can see from the responses. The objective is to develop your "best" plan.

I will ask again, why do you want to avoid the transtracheal injection?

 

[mikey1982]

i mean how much time does everyone have? one person mentioned 20 minute to setup! I like to do ketamine/glyco/ 4% nebulized lidocaine combo. Takes me 5 min, if they cough, propofol..

 

[heathermed]

If you ask 10 anesthesiologists this question you will get 10 different answers. As you can see from the responses. The objective is to develop your "best" plan.

I will ask again, why do you want to avoid the transtracheal injection?

thank you guys for all your suggestions! I personally don't have a problem with trans tracheal but my attending that I will be working with tomorrow does not like using it because she's not comfortable putting a needle in the airway (Im paraphrasing).

 

[GeorgiaAnes]

i mean how much time does everyone have? one person mentioned 20 minute to setup! I like to do ketamine/glyco/ 4% nebulized lidocaine combo. Takes me 5 min, if they cough, propofol..

Hmmm, 5 minutes and you're doing a lidocaine nebulizer? First off, the time it takes to set up the nebulizer and get it going is 5 minutes and you really should have the nebulizer going for >10 minutes at high flow rate. Even then I have never found the nebulizer to be all that effective and have long ditched doing that.

Thanks everyone for some good tips. As someone else said, there are many different ways to get to the same result. The only time I ever do an awake FOI is in the ED (usually between 2-4 AM) for angioedema. Other than that in 5 years of private practice, I've done it maybe 3 times, once in the ED on a GSW and maybe twice on high C spine fx's where the NS wanted it done awake.

Anyways, I like using cetacaine, lidocaine lollipops soaked in 4% lidocaine, glyco, and ketamine. A nasal trumpet loaded with lido jelly after afrin sprayed is good in case I need to go nasally and may help with their breathing. If I do go nasally, then spraying some 4% lidocaine through each nares is what I do next.

I also use the ovassapian and find this gets you almost to the cords. To me it is more difficult when they are sitting bolt upright but the obese angioedema patients, that is my only option. Sometimes they are so swollen it is easier to go nasally on these patients.

Definitely some good tips that I may start instituting, keep 'em coming!

 

[Planktonmd]

glycopyrrolate
dexmeditomidine bolus up to 1 mcg/kg as long as HR/BP tolerate it
ketamine 0.5 mg/kg to 1 mg/kg bolus

nasal airway with lidocaine jelly to dilate nares
2% lidocaine 3 ml with atomizer extension tubing through the nasal tube while they inhale to anesthetize the cords and proximal trachea (I think it's called LMA MADgic)
once the tube is through the cords, propofol until they stop coughing (if they are coughing)

Ketamine + Dex ---> no longer awake inrubation

 

[Planktonmd]

thank you guys for all your suggestions! I personally don't have a problem with trans tracheal but my attending that I will be working with tomorrow does not like using it because she's not comfortable putting a needle in the airway (Im paraphrasing).

The word "uncomfortable" usually means I don't know how to do it and I am too stupid to learn!

 

[Mman]

Ketamine + Dex ---> no longer awake inrubation

OK, cooperative, holding still, maintaining perfect respirations intubation. Why would anybody want to be wide awake for that if they don't have to be?

 

[deleted59964]

....my attending that I will be working with tomorrow does not like using it because she's not comfortable putting a needle in the airway (Im paraphrasing).

wtf?
airway obstruction can happen from minimal sedation or even just topicalisation in some patients.
bleeding into airway from friable airway tumours is another possibility.

Maybe it's just me, but I think if you're not up to sticking a needle in someone's trachea - you should probably not be giving anaesthetics, let alone doing difficult elective airways.
This is an "attending"?

 

[Planktonmd]

OK, cooperative, holding still, maintaining perfect respirations intubation. Why would anybody want to be wide awake for that if they don't have to be?

Your patients are "cooperative" after 1 mg/kg of Ketamine and a bolus of Dex?

 

[Mman]

Your patients are "cooperative" after 1 mg/kg of Ketamine and a bolus of Dex?

No. They first get glycopyrrolate. Then they get up to 1 mcg/kg of Dexmeditomidine. At that point everybody is fairly awake but more cooperative. If they have trouble tolerating the nasal airways, then I start giving a little ketamine, up to as much as 1 mg/kg total. That's why I listed the drugs I give in the order I give them. It's all titrated to effect.

But if you take your average 80 kg adult and give them 80 mcg of precedex they are still coherent and cooperating. If you give them 20 mg of ketamine, the overwhelming majority are still very cooperative and will follow any command you give them. If you give them another 20, most will start to get a little stunned. Rarely have to go up to 1 mg/kg of the ketamine.

 

[Planktonmd]

No. They first get glycopyrrolate. Then they get up to 1 mcg/kg of Dexmeditomidine. At that point everybody is fairly awake but more cooperative. If they have trouble tolerating the nasal airways, then I start giving a little ketamine, up to as much as 1 mg/kg total. That's why I listed the drugs I give in the order I give them. It's all titrated to effect.

But if you take your average 80 kg adult and give them 80 mcg of precedex they are still coherent and cooperating. If you give them 20 mg of ketamine, the overwhelming majority are still very cooperative and will follow any command you give them. If you give them another 20, most will start to get a little stunned. Rarely have to go up to 1 mg/kg of the ketamine.

Sounds reasonable

 

[Gaseous Clay]

Arguing "awake" vs sedated is quite silly. It mainly depends on the scenario. A morbidly obese patient with severe OSA, class IV airway, etc won't get anything from me besides hand holding and topicalization. Take the same known difficult airway but someone who might be otherwise healthy with normal body habitus can get mild sedation with either precedex or ketamine. Sure anyone can crump and go into resp failure but do none of you give pre op versed while the patient is basically alone in their room with nurses outside the door?

 

[urge]

I like my awake fobs awake. Success depends on the amount of local you give. They are actually easier when you can have the pt follow commands, like stick the tongue out or take a deep breath.

 

[deleted171991]

OK, cooperative, holding still, maintaining perfect respirations intubation. Why would anybody want to be wide awake for that if they don't have to be?

I tend to agree here. The best awake fiberoptic I have seen in residency was done with one of our greats, and he used a good dose of droperidol to knock out the patient. No fuss, preceded by some glyco and some nasal phenylephrine in the preop area, and preoxygenation in the OR, and we were ready to go. The patient was zombie, breathing spontaneously but otherwise almost out. Easiest AFOI ever.

Our airway expert would have done a 20-30 minute preop topicalization for the same thing.

As with anything in anesthesia, there are multiple ways to achieve the same outcome, and the more one does the better one becomes.

 

[ranvier]

thank you guys for all your suggestions! I personally don't have a problem with trans tracheal but my attending that I will be working with tomorrow does not like using it because she's not comfortable putting a needle in the airway (Im paraphrasing).

Suggest an angiocath for the transtracheal block. Needle time is fleeting.

 

[bcat85]

Interesting to see all of the different techniques that people use--there clearly isn't a "best way." I think the other thing that hasn't been mentioned yet is just getting facile with the bronchoscope, especially starting out. I found that, sans any change in my technique, my awake fiberoptic intubation skills improved dramatically after doing a couple of months of thoracic where I was using the bronch every day to check tube position, look around, etc. Taking some time to practice with the bronchoscope will likely significantly improve your success rate.

 

[chfo]

This isn't complicated.

Versed 1-2mg immediately, followed immediately with remi infusion for 5-10 minutes, titrated to alertness. No bolus.

While remi infusing: Lido 4% with nebulizer. Transtracheal x2 (1st for anesthesia, 2nd to confirm adequate topicalization (cough with first one, probably no cough with second)). Tube.

If you're decent with fiberoptic scope, you don't need glyco.

 

[cchoukal]

I do a lot of these, both in the OR and ICU, and my routine is similar to what others have mentioned. First, I almost never use glyco. I suppose I could, but I haven't found that my routine without is lacking. Second, a few people have mentioned dex, and I think it's worth mentioning that this has been evaluated in a randomized placebo-controlled trial (done at University of Chicago, not sure if/where they published it) and shown neither to reduce midaz and fentanyl dosing nor to improve intubating conditions. Food for thought, since the bolus and infusion take time to have clinical effect and this drug is expensive (for now).

Anyway, I start with psycho-prophylaxis. I never call this an awake intubation, but rather explain that "most patients have their breathing tube inserted after being all the way off to sleep; you, sir, will have your breathing tube inserted after being PART way off to sleep."
With patient sitting up, I start with 5% lido ointment on a tongue blade. 3 passes, each deeper than the last, and each with the instruction to hold their tongue against their hard palate. Off to the room, midaz, fent, and, still in the gurney, sitting upright, 4% lido spray to tonsils and over top of glottis. I then do 2% lido transtracheal, assuming no contraindications (coagulopathy is the main one I think about). Next is the Ovassapian airway, and then I intubate. I prefer to keep the patient on the gurney so they can be very upright. I prefer the upright position so I'm coming at the patient face-to-face with the scope/tube. I find (think?) this is somehow less troubling for the patient than being flat on their back and having me hover over the top of them. Once the tube is in, I try to have the patient move themselves over to the bed (75% of the time this happens).

That's pretty much it. This can be very quick, and I find the results to be very good (very rare coughing, can't remember ever not being able to get the tube in).

 

[Planktonmd]

I do a lot of these, both in the OR and ICU, and my routine is similar to what others have mentioned. First, I almost never use glyco. I suppose I could, but I haven't found that my routine without is lacking. Second, a few people have mentioned dex, and I think it's worth mentioning that this has been evaluated in a randomized placebo-controlled trial (done at University of Chicago, not sure if/where they published it) and shown neither to reduce midaz and fentanyl dosing nor to improve intubating conditions. Food for thought, since the bolus and infusion take time to have clinical effect and this drug is expensive (for now).

Anyway, I start with psycho-prophylaxis. I never call this an awake intubation, but rather explain that "most patients have their breathing tube inserted after being all the way off to sleep; you, sir, will have your breathing tube inserted after being PART way off to sleep."
With patient sitting up, I start with 5% lido ointment on a tongue blade. 3 passes, each deeper than the last, and each with the instruction to hold their tongue against their hard palate. Off to the room, midaz, fent, and, still in the gurney, sitting upright, 4% lido spray to tonsils and over top of glottis. I then do 2% lido transtracheal, assuming no contraindications (coagulopathy is the main one I think about). Next is the Ovassapian airway, and then I intubate. I prefer to keep the patient on the gurney so they can be very upright. I prefer the upright position so I'm coming at the patient face-to-face with the scope/tube. I find (think?) this is somehow less troubling for the patient than being flat on their back and having me hover over the top of them. Once the tube is in, I try to have the patient move themselves over to the bed (75% of the time this happens).

That's pretty much it. This can be very quick, and I find the results to be very good (very rare coughing, can't remember ever not being able to get the tube in).

Pretty much how I do it... very simple

 

[Mman]

Second, a few people have mentioned dex, and I think it's worth mentioning that this has been evaluated in a randomized placebo-controlled trial (done at University of Chicago, not sure if/where they published it) and shown neither to reduce midaz and fentanyl dosing nor to improve intubating conditions.

The closest I can find to what you mention is this study showing better patient outcome with dexmeditomidine-midaz vs midaz alone. On a personal note I tend to avoid the benzo-narcotic combination during "awake" FOI because I don't like the respiratory compromise. I prefer to get them stunned but still breathing just as good as they were before we started. But there are obviously many ways to skin this cat.

 

[Urzuz]

What size needle do you guys use for your transtracheal? Is it an angiocath?

 

[Noyac]

What size needle do you guys use for your transtracheal? Is it an angiocath?

If I'm just doing the TT then I used a 20g needle so that it squirts quickly but isn't a huge honker that will cause much bleeding. If I'm leaving a catheter in then I use at least an 18g. Something that a guideline can pass through or that I can jet ventilate through or even connect my circuit to and pressurize by closing off the popoff valve some and entrain some O2.
This is why I asked the OP why he/she wanted to avoid the TT. IMO, it is the single most important technique for topicalizing a bad airway especially in a crisis. Do for every AFOI you do and then when you need to do it in a crisis you are comfortable with it. Pts don't usually remember it as much as the other techniques believe it or not. I think this is somewhat because I come from below so they don't really see what I'm doing and make a tiny skin wheel as if I was starting an IV in the spot that I'm going for. Then the next thing they know I'm in and they cough.

 

[soorg]

-First thing you do is talk to the patient about the procedure and why you're doing it in the first place! This provides good anxiolysis.
-Second, 0.2 mg glyco. Versed 2mg, with remifentanil at 0.05 - 0.1 ug/kg/min.
-Place ETT in warm saline to make it more pliable
-Have 'em breathe with their mouth open, which further helps dry out the oropharynx. The mouth must be dry as a bone prior to any topicalization-otherwise it'll be like painting a wet wall, and the local won't work as well.
-4% lido atomizer, followed by brief squirts of benzocaine at the b/l tonsillar pillars (numbs the glossopharyngeal nerve, helping to blunt gag reflex), and a 0.3 sec squirt in the midline.
-drip a few drops of 2% lido in the posterior pharynx by attaching a syringe to a 20g angio. Pull tongue out prior to doing this.
-thread epidural catheter through FOB suction channel, with 2% lido syringe attached to the end
-Place ETT through Williams airway. Advance FOB until you see VCs
-Once you see VCs, spray a cc or so of the 2% lido on them. Wait around 10 seconds, then intubate.
-High five everyone in the OR, get phone numbers, arrange dinners with PACU nurses while the patient is awake with a big honkin' piece of plastic in their trachea, not bucking at all.
-I don't do airway blocks, bc they're not needed.

Rinse and repeat prn.

 

[nimbus]

-Have 'em breathe with their mouth open, which further helps dry out the oropharynx. The mouth must be dry as a bone prior to any topicalization-otherwise it'll be like painting a wet wall, and the local won't work as well.
-.

I know this is the teaching but from personal experimentation I know it's not true. Try spraying lidocaine or sucking on 5%lidocaine ointment yourself. You get very numb very fast. Doesn't matter if your mouth is wet or dry.

 

[Arch Guillotti]

3. 4% lidocaine soaked in gauze. Then I wrap it around my Jackson Krauss right angle forceps and insert it into each side of the mouth for 1-2 minutes. The patient will cough a bit and gag for a few seconds- and I want this to ensure I've covered the entire superior laryngeal nerve. After this I can shove anything into the patient's mouth and there is no gagging or discomfort from the patient. The key is to make sure the gauze is dripping with 4% lidocaine. I don't use nebulizers, aerosolizers, etc. because there is no guarantee you are getting adequate SLN coverage.

This sounds like the glossopharyngeal nerve, not the SLN.

 

[fakin' the funk]

Not surprised by all the different regimens, but I *AM* surprised at how freaking complicated some of them are.

Where I work it is a major PITA just to OBTAIN remi or dex, let alone then setup an infusion. To say nothing of the risk of an added drug...especially a concentrated one like remi...talk about diminishing returns.

- glyco 0.2-0.4mg early, depending on tolerance for tachycardia
- 1-2 mg midazolam in room
- LMA MADgic w/ 4% lidocaine (this is in our regular anesthesia cart) to oropharynx 3-4ml, then bend it 90 degrees at the tip to shoot it caudally down onto epiglottis and glottis while asking patient to "pant like a dog" (distributes into trachea) 4-5ml
- few breaths of 100% to avoid the inevitable peri-securing-the-tube desat
- fiber (no oral airway), tube, done

The weakness of the LMA MADgic is that the tracheal topicalization isn't amazing IME. Tips on using that device specifically much appreciated!

A guy I work with said his favored technique is "have them gargle 4% lidocaine solution, put the tube in." I thought that sounded pretty parsimonious.

 

[Libertas]

why would you do a transtracheal and then not leave the catheter in?

 

[Hoya11]

I do a lot of these, both in the OR and ICU, and my routine is similar to what others have mentioned. First, I almost never use glyco. I suppose I could, but I haven't found that my routine without is lacking. Second, a few people have mentioned dex, and I think it's worth mentioning that this has been evaluated in a randomized placebo-controlled trial (done at University of Chicago, not sure if/where they published it) and shown neither to reduce midaz and fentanyl dosing nor to improve intubating conditions. Food for thought, since the bolus and infusion take time to have clinical effect and this drug is expensive (for now).

Anyway, I start with psycho-prophylaxis. I never call this an awake intubation, but rather explain that "most patients have their breathing tube inserted after being all the way off to sleep; you, sir, will have your breathing tube inserted after being PART way off to sleep."
With patient sitting up, I start with 5% lido ointment on a tongue blade. 3 passes, each deeper than the last, and each with the instruction to hold their tongue against their hard palate. Off to the room, midaz, fent, and, still in the gurney, sitting upright, 4% lido spray to tonsils and over top of glottis. I then do 2% lido transtracheal, assuming no contraindications (coagulopathy is the main one I think about). Next is the Ovassapian airway, and then I intubate. I prefer to keep the patient on the gurney so they can be very upright. I prefer the upright position so I'm coming at the patient face-to-face with the scope/tube. I find (think?) this is somehow less troubling for the patient than being flat on their back and having me hover over the top of them. Once the tube is in, I try to have the patient move themselves over to the bed (75% of the time this happens).

That's pretty much it. This can be very quick, and I find the results to be very good (very rare coughing, can't remember ever not being able to get the tube in).

copious nasal neo
glyco 0.4-0.8mg
midaz 2-8mg
fent 50-100 mcg
a few lido coated trumpets of increasing size, the last one having a longitudinal slit for removal
4% lido neb with FM in and out through nose while changing trumpets
lubed, saline warmed 7.0 tube loosely taped to top of scope
ketamine 20-40mg just before scope insertion
insert scope through nose through nasal airway, not through tube
slow and steady ensuring midline, see VCs and optimize position of scope.
advance scope through cords quickly and down relatively deep into airway, sometimes past carina
remove nasal airway
give propofol bolus 100-200 as i pass the tube into the airway
blow up cuff, ventilate, confirm ETCO2 and that tube is in airway with scope
roc
then optimize tube position above carina

not sure why the goal with some of the above plans is to have them tolerate the tube in the airway awake... once you are in with the tube, put them to sleep. no matter how well topicalized they are its just unneccsary.

 

[chmd]

I do a lot of these, both in the OR and ICU, and my routine is similar to what others have mentioned. First, I almost never use glyco. I suppose I could, but I haven't found that my routine without is lacking. Second, a few people have mentioned dex, and I think it's worth mentioning that this has been evaluated in a randomized placebo-controlled trial (done at University of Chicago, not sure if/where they published it) and shown neither to reduce midaz and fentanyl dosing nor to improve intubating conditions. Food for thought, since the bolus and infusion take time to have clinical effect and this drug is expensive (for now).

Anyway, I start with psycho-prophylaxis. I never call this an awake intubation, but rather explain that "most patients have their breathing tube inserted after being all the way off to sleep; you, sir, will have your breathing tube inserted after being PART way off to sleep."
With patient sitting up, I start with 5% lido ointment on a tongue blade. 3 passes, each deeper than the last, and each with the instruction to hold their tongue against their hard palate. Off to the room, midaz, fent, and, still in the gurney, sitting upright, 4% lido spray to tonsils and over top of glottis. I then do 2% lido transtracheal, assuming no contraindications (coagulopathy is the main one I think about). Next is the Ovassapian airway, and then I intubate. I prefer to keep the patient on the gurney so they can be very upright. I prefer the upright position so I'm coming at the patient face-to-face with the scope/tube. I find (think?) this is somehow less troubling for the patient than being flat on their back and having me hover over the top of them. Once the tube is in, I try to have the patient move themselves over to the bed (75% of the time this happens).

That's pretty much it. This can be very quick, and I find the results to be very good (very rare coughing, can't remember ever not being able to get the tube in).

All we have is 2% lido jelly and I wish we had 5%. I paint the tonsils and posterior tongue with it after the nebs. I haven't used glyco but I think I will start after reading this thread. Then the lido atomizer curved like a lightwanded ett to spray the cords (pt should tolerate pretty well). Then a little midaz/ketamine and brinchoscopy while facing pt who is sitting upright.

 

[deleted59964]

Not surprised by all the different regimens, but I *AM* surprised at how freaking complicated some of them are.

Where I work it is a major PITA just to OBTAIN remi or dex, let alone then setup an infusion. To say nothing of the risk of an added drug...especially a concentrated one like remi...talk about diminishing returns.

do you use remi much?
1. fair enough if its a PITA for you to obtain, it is no more difficult for me than to get fentanyl
2. put 2mg in 40mL (50mcg/ml), get pt weight in kg (or estimate it), divide by 10, multiply by 1.2 -- gives ml/hr for 0.1 mcg/kg/min (e.g.. 80kg --> 8 X 1.2 = 9.6ml/hr) = 0.1mcg/kg/min == not that hard
3. it's the only drug I give other than glyco
4. it's ultra short acting, rapidly titratable, organ independent metabolism, and reversible with naloxone.
5. main side effect is bradycardia, but you give glyco first

 

[soorg]

And do it with patient sitting up, with you on pt's right side.

 

[cockblockandrun]

This sounds like the glossopharyngeal nerve, not the SLN.

With proper technique, i.e. inserting right- angle forceps with handle coming out of patient's mouth- you can block both GN and SLN.

http://www.pitt.edu/~regional/Airway Blocks/airway_blocks.htm

https://books.google.com/books?id=v...ause forceps superior laryngeal nerve&f=false

 

[deleted171991]

give propofol bolus 100-200 as i pass the tube into the airway
blow up cuff, ventilate, confirm ETCO2 and that tube is in airway with scope

In that order?

 

[fakin' the funk]

do you use remi much?
2. put 2mg in 40mL (50mcg/ml), get pt weight in kg (or estimate it), divide by 10, multiply by 1.2 -- gives ml/hr for 0.1 mcg/kg/min (e.g.. 80kg --> 8 X 1.2 = 9.6ml/hr) = 0.1mcg/kg/min == not that hard

I do use it. And I'm familiar with its properties.

And while your 5 steps of math may be "not that hard," it's still a lot of time-consuming stuff to do for zero-to-marginal benefit.

 

[fakin' the funk]

This isn't complicated.

Versed 1-2mg immediately, followed immediately with remi infusion for 5-10 minutes, titrated to alertness. No bolus..

You have 5-10 minutes to do your AFOI? Um, why?

 

[fakin' the funk]

And do it with patient sitting up, with you on pt's right side.

I do it with the pt supine and me at HOB. The last things I want with a lubed-up ETT flapping in the breeze and a patient who needs induction are the inverted anatomy and having to jumprope the monitors.