awake fiberoptic regimen

[deleted59964]

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.

how exactly is it time consuming to put some remi in a syringe and set the pump to about 10ml/hr for an 80kg patient?

---

Members don't see this ad.

 

[deleted59964]

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.

how exactly is it time consuming to put some remi in a syringe and set the pump to about 10ml/hr for an 80kg patient?

 

[soorg]

It's easier to pass the ETT if pt is sitting up, plus less scary from the pt's point of view.

 

[cchoukal]

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.

I look at this somewhat differently and would suggest that the 30 seconds of coughing and bucking between the insertion of an ETT into an under-prepared trachea while the propofol is injected and exerts its effect is unnecessary (and unsightly).

 

[Hoya11]

I look at this somewhat differently and would suggest that the 30 seconds of coughing and bucking between the insertion of an ETT into an under-prepared trachea while the propofol is injected and exerts its effect is unnecessary (and unsightly).

just because i am pushing propofol you are assuming the trachea is under prepared, its not.

so ill ask again, what is the justification for keeping someone awake with the tube in the trachea? even though it is just so perfectly numb that they dont know its there, which we all know is never the case all the time. arent you eventually going to put them to sleep for the surgery? no one is impressed that they tolerate the tube, just put them to sleep.

 

[chfo]

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

Awake fiberoptics should be very, very rare procedures. If you're doing a lot of them, you're overusing.

If you have cord compression and you want a good neuro exam afterwards, and no coughing during intubation, then you should take your time.

 

[Planktonmd]

Awake fiberoptics should be very, very rare procedures. If you're doing a lot of them, you're overusing.

If you have cord compression and you want a good neuro exam afterwards, and no coughing during intubation, then you should take your time.

Why does it have to be "very very" rare???

 

[Noyac]

I look at this somewhat differently and would suggest that the 30 seconds of coughing and bucking between the insertion of an ETT into an under-prepared trachea while the propofol is injected and exerts its effect is unnecessary (and unsightly).

You are correction that it is unsightly. Unnecessary is a difference of opinion and on a case by case basis.
Not long ago I post a case here of an airway emegency I had one evening. It was the worst airway I've ever had as far as I can remember. Everything I tried with regards to topicalization failed due to the massive amount of blood in the airway preventing the lidocaine from penetrating or even making contact with the mucous membranes. The transtracheal injection didn't even work because of the massive amount of blood aspirated. So when I saw a bubble come up from somewhere with my FO scope i went with it and drove the scope and then tube in. I still could not make any sense of what I was seeing so I came out and connected the circuit. I was not about to push propofol because I didn't know where I was so I looked of ETCO2 and just turned on the gas. As I would attempt to inflate the cuff he would begin to cough even more than he already was. So I looked at the OR crew and said we are gonna have to hold this one down until he either goes to sleep or doesn't. Luckily for me he went to sleep pretty quickly. Which I assumed confirmed tube placement. Man was that a **** show.

After it was all over I started to think more about it. I guess he still could have gone off to sleep if I was in the goose since the Sevo would still have been what he was breathing. But at least this way he was still breathing.

 

[nap$ter]

for oral awake foi:

1 - propofol ready
2 - glyco
3 - 4% lido via atomizer shoved/sprayed deep until pt stops gagging
4 - the right light sedation if absolutely necessary (which is almost never with the right preop verbal prep)
5 - assistant pulls tongue forward, FOB, fastrach LMA ETT (never ever hangs up)
6 - etco2, propofol

 

[Spinach Dip]

Sedatives are overrated. All you need is a gallon of lido and a cooperative patient.

 

[Ezekiel2517]

Criticizing other people's AFOI regimens is stupid. As we all know, unless emergent, AFOI is all about the style points. Use whatever method that makes you look like a bad ass.

 

[bkell101]

has anybody seen the video on emcrit of the residents doing awake glidescope? what are your thoughts on this?

 

[Arch Guillotti]

has anybody seen the video on emcrit of the residents doing awake glidescope? what are your thoughts on this?

Have not seen the video but I have done a couple and they went great.

 

[Noyac]

I agree with Arch, it is a fantastic way to manage the difficult airway.

 

[bkell101]

I agree with Arch, it is a fantastic way to manage the difficult airway.

What technique did you guys? Same or different regimen than the afoi?

 

[Arch Guillotti]

What technique did you guys? Same or different regimen than the afoi?

Same.

 

[floridaboy18]

This is why I love our training at Wake Forest. I do three nerve blocks (SLN, glossopharyngeal, and trans-trach). 2% for SLN and Glossopharyngeal. 4% for transtrach (less than 4% doesn't seem to work for this because it is a topical block). From starting my block to tube being in is approximately 5 minutes. No 20 minute nebulizer, topical with gagging. It can be unsightly done that way and requires boat loads of sedation. Most sedation we do is 50 mcg fentanyl, 1 mg of midaz, and 10-20mg of ketamine. Some patients reuire more...but the point of an awake is to keep them spontaneously breathing. So, we insure that happens by using reversable agents or ones that keep them breathing. Patient still follows commands enough to do glossopharnygeal block and breaths spontaneously throughout.

I can topicalize when I want to. Very comfortable with this approach, too. But why not do blocks? Looks pretty, patient is comfortable throughout, and the surgeons never mind us doing it (when indicated) because it never slows them down.

 

[Spinach Dip]

has anybody seen the video on emcrit of the residents doing awake glidescope? what are your thoughts on this?

Uh, why not?

This is why I love our training at Wake Forest. I do three nerve blocks (SLN, glossopharyngeal, and trans-trach). 2% for SLN and Glossopharyngeal. 4% for transtrach (less than 4% doesn't seem to work for this because it is a topical block). From starting my block to tube being in is approximately 5 minutes. No 20 minute nebulizer, topical with gagging. It can be unsightly done that way and requires boat loads of sedation. Most sedation we do is 50 mcg fentanyl, 1 mg of midaz, and 10-20mg of ketamine. Some patients reuire more...but the point of an awake is to keep them spontaneously breathing. So, we insure that happens by using reversable agents or ones that keep them breathing. Patient still follows commands enough to do glossopharnygeal block and breaths spontaneously throughout.

I can topicalize when I want to. Very comfortable with this approach, too. But why not do blocks? Looks pretty, patient is comfortable throughout, and the surgeons never mind us doing it (when indicated) because it never slows them down.

If I am reading your post correctly, nerve blocks completely (or almost completely) block retching, while topical spraying does not. Correct?

 

[Noyac]

This is why I love our training at Wake Forest. I do three nerve blocks (SLN, glossopharyngeal, and trans-trach). 2% for SLN and Glossopharyngeal. 4% for transtrach (less than 4% doesn't seem to work for this because it is a topical block). From starting my block to tube being in is approximately 5 minutes. No 20 minute nebulizer, topical with gagging. It can be unsightly done that way and requires boat loads of sedation. Most sedation we do is 50 mcg fentanyl, 1 mg of midaz, and 10-20mg of ketamine. Some patients reuire more...but the point of an awake is to keep them spontaneously breathing. So, we insure that happens by using reversable agents or ones that keep them breathing. Patient still follows commands enough to do glossopharnygeal block and breaths spontaneously throughout.

I can topicalize when I want to. Very comfortable with this approach, too. But why not do blocks? Looks pretty, patient is comfortable throughout, and the surgeons never mind us doing it (when indicated) because it never slows them down.

I agree with most of your approach. Just haven't needed the glossopharyngeal block much these days. Looking back at my airway case a couple months back, it would have been impossible. The SLN might have helped some but it was the tongue that was so painful on my pt at that time.
The sedation part I don't exactly follow tho. Why use versed and fentanyl when you are using ketamine? I understand that you want something reversible but it's the ketamine that is sedation get your pt when you are using such small doses of the others so it doesn't matter that they are reversible. Just my thoughts here. I'm sure it works well.

Btw what needle do you use for your glossopharyngeal block?

 

[Arch Guillotti]

Btw what needle do you use for your glossopharyngeal block?

My guess would be a small spinal needle.

 

[Noyac]

My guess would be a small spinal needle.

That's what I've used.

 

[floridaboy18]

I agree with most of your approach. Just haven't needed the glossopharyngeal block much these days. Looking back at my airway case a couple months back, it would have been impossible. The SLN might have helped some but it was the tongue that was so painful on my pt at that time.
The sedation part I don't exactly follow tho. Why use versed and fentanyl when you are using ketamine? I understand that you want something reversible but it's the ketamine that is sedation get your pt when you are using such small doses of the others so it doesn't matter that they are reversible. Just my thoughts here. I'm sure it works well.

Btw what needle do you use for your glossopharyngeal block?

You had the needle right. We use a 25 gauge spinal needle for the glossopharyngeal. We are taught a bit differently there, too. We aim for the anterior pillar (palatoglossal fold). If you get the posterior pillar, it is a denser block...but unnecessary as long as you don't ride the palate with your fiber. If you stay along the tongue (this is easily accomplished in most cases) you don't need the palate covered. You could topicalize this if absolutely necessary. We also use a Miller 2 blade to expose the block. So, typically the tongue isn't really an issue. I have had a patient or two with massive tongues where I was still able to visualize with the miller 2, but was unable to avoid the palate and had to topicalize for a couple of minutes with 5% lidocaine gel.

The main goal is to keep the patient spontaneously breathing and cooperative. So, versed and fentanyl up front (low dose) to allow this. I recognize that at low doses ketamine likely won't cause any untoward effects, but a little midaz seems like a nice touch whenver I give it. I have seen some patients go off the deep end with even small doses. Don't exactly understand why, but having versed on board is nice, I think.

For the other blocks I use a 23 gauge needle for SLN (also done differently, we don't walk off the cornu of the hyoid bone...it is done midline at the thyroid cartiledge at 10 and 2 o'clock). We use a 20 gauge for trans-tracheal so that it can be given quickly once you aspirate air. Smaller gauges get you trouble because it takes too long to inject rapidly.

All that said, if the patient's anatomy (large goiter) or situation (platelets are 50,000 or INR of 4) calls for a different approach to the awake fiber, happy to do it with glyco, topical, or 4% nebulized lidocaine...these techniques simply take longer and often aren't as pretty.

One additional thing that often goes unnoticed with trans-tracheal blocks...if you perform this block routinely for your awakes in the rare instance that you need to trans-tracheally jet ventilate someone or cut down for an emergent airway you are intimately familiar with the anatomy because you have felt it 100 or more times.

For what it is worth, several of our faculty did a workshop in NOLA for the ASA last year. I know they plan to do another one this year. It is a very small workshop, though. People gave rave reviews of the workshop last year.

 

[floridaboy18]

If I am reading your post correctly, nerve blocks completely (or almost completely) block retching, while topical spraying does not. Correct?

Not exactly what I meant if I implied that. You give someone some glyco and a 4% nebulizer.... not really going to need much else. It just takes 20-30 minutes.
If you topicalize with oral gel and spray the cords with lidocaine...still gonna cough when you get into the trachea. This is when you get that unwanted wretching effect. So, if I was going to go the long about way to do an awake....would just use 4% nebulizer after some glyco.

 

[floridaboy18]

And, yes, when blocks are done correctly (like the two I did last Friday) the patient will not buck, cough, gag. It is a beautiful thing. Had a conversation with the patient, made them move all four extremities (myelopathic cervical spine case) and off to sleep they went.

Could we have approached that airway differently and been successful? Yes. But sometimes an awake fiber is what needs to be done...and since ours don't add additional time that causes case delays, our surgeons (neuro in particular) are more than happy for us to do them whenever we want as long as it is reasonable.

I'll graduate with probably 50 awake fibers and 100-200 fiberoptic intubations (nasal, awake nasal, awake oral, asleep oral).

 

[Gaseous Clay]

And, yes, when blocks are done correctly (like the two I did last Friday) the patient will not buck, cough, gag. It is a beautiful thing. Had a conversation with the patient, made them move all four extremities (myelopathic cervical spine case) and off to sleep they went.

Could we have approached that airway differently and been successful? Yes. But sometimes an awake fiber is what needs to be done...and since ours don't add additional time that causes case delays, our surgeons (neuro in particular) are more than happy for us to do them whenever we want as long as it is reasonable.

I'll graduate with probably 50 awake fibers and 100-200 fiberoptic intubations (nasal, awake nasal, awake oral, asleep oral).

Congrats on those numbers. Wake Forest is a great place to train and it sounds like you took full advantage of the academic institution. I only did a few awakes during residency. A lot of us "practiced" nasal fiberoptics in either the peds dental room or an OMFS case. It's definitely a different ball game in the ED with a 300 lbs angioedema patient who can barely breath sitting bolt upright at 3 AM. Your training will serve you well.

 

[chmd]

And, yes, when blocks are done correctly (like the two I did last Friday) the patient will not buck, cough, gag. It is a beautiful thing. Had a conversation with the patient, made them move all four extremities (myelopathic cervical spine case) and off to sleep they went.

Could we have approached that airway differently and been successful? Yes. But sometimes an awake fiber is what needs to be done...and since ours don't add additional time that causes case delays, our surgeons (neuro in particular) are more than happy for us to do them whenever we want as long as it is reasonable.

I'll graduate with probably 50 awake fibers and 100-200 fiberoptic intubations (nasal, awake nasal, awake oral, asleep oral).

I'm jealous.

 

[Mman]

Why does it have to be "very very" rare???

Because that's about as often as it needs to be done. I think we do about 1 awake FOI out of every 3000-5000 cases or so (on average). And we do all kinds of ENT procedures and super huge gastric bypasses and the like. How often do you do them?

 

[Mman]

From starting my block to tube being in is approximately 5 minutes.

No offense, but if your median time to the tube being in from the time you start your block, you are doing awake FOIs on a lot more patients than you likely need to. The truly difficult and terrible airways that require an awake FOI are not that easy for technical reasons.

 

[floridaboy18]

No offense, but if your median time to the tube being in from the time you start your block, you are doing awake FOIs on a lot more patients than you likely need to. The truly difficult and terrible airways that require an awake FOI are not that easy for technical reasons.

You are missing the point. Do you truly want to practice your mere five awake fiberoptic intubations on the most difficult of airways? Absolutely not. Can I put a tube in those people using an awake technique still faster than the glyco + nebulizer or topical? absolutely. No one can pretend to become an expert at something by doing 5 or 10 awakes during residency on the most challenging of airways.

I've done my fair share of very difficult intubations (from pierre robin sequence kids that are a month old to patients with tumors or hematomas in difficult places with a radiated neck) on people using an awake technique and because of the practice I was able to obtain on the "softer" calls (cervical myelopathies, unstable C-spine patients, etc), they were not difficult. Most people stay away from AFOI's because they have not done enough and they are not comfortable with them. They would rather try and find another way than to do an AFOI. I would much rather have the problem of having "too good of training" where I am doing "too many" where even the technically difficult ones take 10 minutes than to come out residency not having done enough and being uncomfortable when its truly necessary and not look like an expert to any one (surgeon, colleague, CRNA) that is watching when I do it. That will not be a problem of mine.

You say "too many." I say I've gotten very good training. More tools in the shed to choose from.

And when can you ever do enough of something in our field, particularly the most difficult of something?

 

[floridaboy18]

Because that's about as often as it needs to be done. I think we do about 1 awake FOI out of every 3000-5000 cases or so (on average). And we do all kinds of ENT procedures and super huge gastric bypasses and the like. How often do you do them?

If this is true, you are practicing on a very different demographic of patient's than we do. OR there are more patients that probably would warrant an AFOI but instead a different route is chosen because of discomfort, surgeon complaints because it takes too long, etc. For these reasons, I say again that you can never have done "too many" of this procedure.

 

[Mman]

I would much rather have the problem of having "too good of training" where I am doing "too many" where even the technically difficult ones take 10 minutes than to come out residency not having done enough and being uncomfortable when its truly necessary and not look like an expert to any one (surgeon, colleague, CRNA) that is watching when I do it. That will not be a problem of mine.

You say "too many." I say I've gotten very good training. More tools in the shed to choose from.

And when can you ever do enough of something in our field, particularly the most difficult of something?

You are mistaking my comments for criticisms of your residency training. I'm not. I did a bunch of awake FOIs in residency for the sake of learning. I'm merely pointing out that if you can do them that fast, you are doing them on a different patient population than simply the ones that need it. Gotta recognize when you are doing something simply to practice and because you can and when you need to do something because it's your only option.

 

[Mman]

If this is true, you are practicing on a very different demographic of patient's than we do. OR there are more patients that probably would warrant an AFOI but instead a different route is chosen because of discomfort, surgeon complaints because it takes too long, etc. For these reasons, I say again that you can never have done "too many" of this procedure.

You can never have done too many of anything. How many PA caths do you float as a resident? A lot more than you do in the real world. Getting good at something as a resident is important, but when you get out in the real world you need to learn when you don't need to do it.

 

[floridaboy18]

You can never have done too many of anything. How many PA caths do you float as a resident? A lot more than you do in the real world. Getting good at something as a resident is important, but when you get out in the real world you need to learn when you don't need to do it.

You are right. I agree completely. And I know the difference as well. As an attending, this likely will be true for me, too, that I will not do as many, but when the time calls for it, it will be as straight forward as it can be.

I'll be more than happy to say that being too well trained ended up being a problem of mine and that I didn't need half the things I learned. I would hate to have it the other way around.

 

[amyl]

So the other day my patient says his last surgery was cancelled bc they couldn't get the breathing tube, not even awake. He's bmi 60 and all the problems that go with it asking for versed in preop bc he's really nervous after how things went last time. Now he needs an av fistula and surgeon says his arm is so fat and he will have to dig up in their so he needs general. His neck looks like it's 5 inches thick of adipose.... He really has no chin it's just a big mass of fat, huge fat cheeks, no neck... All his bmi in his upper half. I talk about regional and surgeon is like well you can try it before you have to put him to sleep but patient refuses despite a long convo. Transtracheal not really an option.... Idk what needle would be long enough or where the hell to stick besides the middle of the submandibular blubber of where I guess the chin would be.
No one can find the atomizer (we suspect it was borrowed... Lots of meth heads in the area lol). So I start precedex with the bolus and actually he gets pretty drowsy. Midaz glyco ketamine. Viscous lido on a tongue blade and lta him as best I can. Place the oral guide which he tolerates well. I start with the fiberoptic and can't see ****, redundant fat all over.... So I grab the king scope (glide scopes much cheaper knock off) and takes two seconds to get the tube in perfectly and he didn't gag once. I did one in residency too and it went perfect. This guy says he doesn't remember the tube going in this time .
If the airways a problem due increased bmi I think video DL (drowsy, topicalized) may be the way to go. It's just so much faster than the fiberoptic

 

[Planktonmd]

Because that's about as often as it needs to be done. I think we do about 1 awake FOI out of every 3000-5000 cases or so (on average). And we do all kinds of ENT procedures and super huge gastric bypasses and the like. How often do you do them?

Maybe that's why you think AFOI is such a big deal... you just don't practice enough to stay proficient!

 

[Planktonmd]

So the other day my patient says his last surgery was cancelled bc they couldn't get the breathing tube, not even awake. He's bmi 60 and all the problems that go with it asking for versed in preop bc he's really nervous after how things went last time. Now he needs an av fistula and surgeon says his arm is so fat and he will have to dig up in their so he needs general. His neck looks like it's 5 inches thick of adipose.... He really has no chin it's just a big mass of fat, huge fat cheeks, no neck... All his bmi in his upper half. I talk about regional and surgeon is like well you can try it before you have to put him to sleep but patient refuses despite a long convo. Transtracheal not really an option.... Idk what needle would be long enough or where the hell to stick besides the middle of the submandibular blubber of where I guess the chin would be.
No one can find the atomizer (we suspect it was borrowed... Lots of meth heads in the area lol). So I start precedex with the bolus and actually he gets pretty drowsy. Midaz glyco ketamine. Viscous lido on a tongue blade and lta him as best I can. Place the oral guide which he tolerates well. I start with the fiberoptic and can't see ****, redundant fat all over.... So I grab the king scope (glide scopes much cheaper knock off) and takes two seconds to get the tube in perfectly and he didn't gag once. I did one in residency too and it went perfect. This guy says he doesn't remember the tube going in this time .
If the airways a problem due increased bmi I think video DL (drowsy, topicalized) may be the way to go. It's just so much faster than the fiberoptic

I think in difficult situations you should always do what you are best at no matter what that might be.

 

[pgg]

For what it is worth, several of our faculty did a workshop in NOLA for the ASA last year. I know they plan to do another one this year. It is a very small workshop, though. People gave rave reviews of the workshop last year.

Lots of the ASA workshops looked good last time I went. I just wasn't willing to pay another $450 or whatever it was to find out.

 

[Ezekiel2517]

I did quite a few AFOI in residency. I remember co-residents bragging bout how many AFOI they were doing. After you do a few you realize how simple it is and that it's no big deal. Like I said , it's just about style points.
Haven't done a single AFOI as an attending. Haven't needed to. And I do every type of case imaginable. Glidescope has pretty much made it irrelevant. I think it's more important to perfect your glidescope skills. I see a lot of people who still struggle getting the tube in. I think it's also more important to learn as a resident how to do an emergent surgical airway/cric

 

[BLADEMDA]

I did quite a few AFOI in residency. I remember co-residents bragging bout how many AFOI they were doing. After you do a few you realize how simple it is and that it's no big deal. Like I said , it's just about style points.
Haven't done a single AFOI as an attending. Haven't needed to. And I do every type of case imaginable. Glidescope has pretty much made it irrelevant. I think it's more important to perfect your glidescope skills. I see a lot of people who still struggle getting the tube in. I think it's also more important to learn as a resident how to do an emergent surgical airway/cric

I'd trade 20 AFOI for one emergent Cric with an experienced attending teaching me.

 

[Mman]

Maybe that's why you think AFOI is such a big deal... you just don't practice enough to stay proficient!

In no way do I think AFOI is a "big deal". I find them interesting and mildly fun to do, but simply don't have a need for it very often. We do awake tracheostomies more often than awake fiberoptic intubations.