What's your LA protocol for awake FOB?

[urge]

For me: nebulized 5ml 4% lidocaine, atomized 5ml 4% lidocaine, and 2 sprays of cetacaine.

Still a lot of coughing most of the time. I almost always need to supplement with good doses of ketamine or dex.

Anyone has a bullet proof concoction?

Plank, you seem to be the guy here doing the most. What are you using?

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[coprolalia]

Bulletproof concotion? I don't know about that. We use different strategies depending on the situation. But, I don't know if there is any better strategy.

The simplest, and what seems to work the best, is similar to what you describe. Enough midazolam to make them sleepy, enough fentanyl to make them comfortable, a lot of cetacaine in the oropharynx, and even more talking to them before you start to ensure that they know what they're going to go through.

Precedex is great, but is expensive and takes at least 30 minutes to get them to the right "state" of pre-induction. Still, use it when warranted. Overall, though, I've found that it doesn't add much extra that's helpful (having done enough with/without it to be a decent judge). As one of my attendings recently said, "It's a long run for a short slide."

Rarely do we do superior laryngeal nerve block. That's a LOT of set-up, and you have to potentially deal with paralyzed cords post-procedure. But, this is probably the most effective for someone who otherwise won't tolerate a tube being stuck through their cords while awake (heavy smoker, extreme anxiety, etc.)

There's many different ways to climb this tree. I've done it multiple different ways. Usually, the way described in the first paragraph is sufficient. And, it also depends on whether or not you're going to go oral or nasal as to how much pre-prep you need.

-copro

 

[seinfeld]

nebulized 4%, then remi 0.1-0.4 mcg/kg/min, if you give midaz then more careful with the remi. the best part is they are awake breathing but really comfortable. the thing i have found to help the most is not to touch the oropharynx with the scope

 

[seinfeld]

nebulized 4%, then remi 0.1-0.4 mcg/kg/min, if you give midaz then more careful with the remi. the best part is they are awake breathing but really comfortable. the thing i have found to help the most is not to touch the oropharynx with the scope

 

[Planktonmd]

For me: nebulized 5ml 4% lidocaine, atomized 5ml 4% lidocaine, and 2 sprays of cetacaine.

Still a lot of coughing most of the time. I almost always need to supplement with good doses of ketamine or dex.

Anyone has a bullet proof concoction?

Plank, you seem to be the guy here doing the most. What are you using?

Versed + Robinul + Nebulized 4% Lido in the holding area.
In OR:
Many times Remifentanyl.
Atomized 4% Lido to oropharynx (and to nose if for some reason you are doing nasal).
Sometimes Pull tongue out and hold it with gauze then pour some lidocaine Jelly on the back of the tongue and ask the patient to swallow, they will aspirate the lido.
Transtracheal block with 4cc Lido 4%.
I don't do SLN blocks.

 

[ZA_Gasman]

Tried all of the above - don't like the nebulised lido - just doesn't seem to work and when you are using lots of lido in different parts of the airway, I don't like not knowing where I am toxic dose wise. Must say that SLN block have made it a lot easier, but I only use 0.5ml each side, have much less retching and discomfort. 2 well directed sprays to the back of the throat and 2 sprays to the target nostril.

Have seen some reports, can't remember where of haemodynamic instability following SLN blocks - concerns me a little bit, but seem to remember that they were using 3-4ml each side, which really seems like overkill.

I like a little propofol (we don't have easy access to dexmed) - 15-30mg in an adult, plus a little fentanyl to take the edge off. Also, I find that ease of FOB is directly proportional to patient IQ and buy-in, so I spend a lot of time explaining what we're going to do/doing. Having said all the above... Different tricks will work in different patients.

 

[Noyac]

I feel the biggest difference is the transtracheal block. The rest doesn't matter as much.

 

[Jeff05]

swish, garge and swallow some 4% viscous lido. put in ovasapien. use whatever device you prefer to spray some lido at the posterior pharynx.
transtracheal block. works everytime.

 

[Noyac]

swish, garge and swallow some 4% viscous lido. put in ovasapien. use whatever device you prefer to spray some lido at the posterior pharynx.
transtracheal block. works everytime.

Pretty much how I do it as well.

 

[militarymd]

I believe that the key to awake intubations is the sedation component of the intubation.

Most poorly topicalized airways seem related to inadequate narcotic use during the topicalization process.

I routinely do my awakes in preop before I wheel my patients into the OR.

 

[urge]

Has anyone FOB'ed him/herself?

 

[RT2MD]

In the bronchoscopy rooms where I work, we use Atomized 2% lido in the oralpharynx, xylocaine jelly up the nose (snort) and 1% lido in the lungs (on the cords, etc) for the bronch. This is coupled with Versed and Fent. That's how the pulm docs do it, anyway.

In pre op, I have been called to do nebulized 4% lido aerosols before, but we stopped using them in the bronch lab, finding that they were mostly ineffective.

Part of the problem with the 4% lido being aerosolized is that it contains preservatives (says on bottle - topical use only)... I dunno how this would affect reactive airways.

Thanks!

 

[huktonfonix]

I feel the key to a successful topicalization in most people is drying out the airway. glyco helps. I also hand them a 4x4 and tell them to spit out or swallow anything in their mouth. Then I have them take deep breaths through their mouth with or without oxygen. when their mouth feels really dry, then I spray them down with 4% lido from the tongue back to the oropharynx asking them to take deep breaths as I go along so some of it hits the trachea (occ I'll use a transtracheal). This seems to numb them up well and fast (5-10 min for the whole process). I also use a little midaz and fentanyl as needed. Ketamine for the "awake" FBO on kids and sometimes adults.

 

[proman]

Remi works + lido jelly in the nose works but I really like glyco + serial dilation with nasal trumpets coated in lido jelly + the MAD atomizing 4% lido through the nasal trumpet. We put the tube half-way in then pass the scope + more MAD through that. Squirt the cords with lido and no sedation is needed at all. Had a patient sit breathing through the tube while the ortho residents tried to figure out how to use a halo + Mayfield.

 

[pd4emergence]

no SLN blocks for me, aerosolize about 5 cc 4% lido, glyco in preop, versed in pre op, back to the room, some more versed if they are pretty alert, 30 or so of ketamine, some fentanyl. Have them open and spray'em down with hurricaine spray. I do some transtracheals but only on people with good landmarks (which is almost never nowadays). I do the viscous lidocaine thing for EGD's, I may start trying it for FOI's.

 

[cchoukal]

I think the dryness is key, as well. We do a lot of head and neck onc here, and so we have a lot of potentially difficult airways that get awake FOBs in the ORs and in addn, have a few CC attgs who like to do urgent airways on the floor awake. For the elective FOBs, glyco, fent, midaz, 4% solution, all the way back until they gag, being careful to try to spray the soft palate and posterior oropharynx. 5% ointment to the tongue and base of the ovassapian airway. epidural catheter thru the working channel of the FOB luer-locked to a 5ml syringe of 4%. this is to spray the cords and subglottic trachea.

Out on the floor, it's basically 4% lido to oropharynx, aggressive use of 5% ointment to the tongue and base of tongue, cuz that's where my huge steel blade's going. Add a little brutane and we can do pretty much all of these awake...

 

[urge]

In my quest for bullet proof topicalization, I topicalized myself the other day with nasal lidocaine jelly and atomized lido for throat while taking deep breaths. No glyco, no sedation. I put a nasal trumpet with lidocane ointment to dilate. I was able to bronchoscope myself both nasally and orally. Cords were the hardest to numb. You have to aspirate the lido to have adequate topicalization. It's not that bad if everything is numb. I didn't pass a tube, though. Only thing is if you push the scope far down the trachea coughing ensues pretty quickly. I guess a transtracheal would work for that, but I wasn't going to try that.

I must have used between 400 and 600 mg of lidocaine. I was a bit lightheaded at the end but it was a good learning experience. Now I can call the pts pansies.

 

[kmurp]

Viscous Lido in preop. Works best if they can gargle it. 4% lido atomizer in OR. Lido goop on intubating airway and 4% thru this. 1cc 4% transtracheal. If bad landmarks shoot the 4% thru the scope into the trachea. Stopped doing sup laryngeal blocks-take a bit of time to set up... Sedation-whatever works that day in an amount inversely related to my fear of losing the airway. FWIW, I measure the amount of 4% lido that I use to avoid toxicity in smaller patients-but most of the time these days, the indication is morbid obesity so lido toxicity isn't a problem.

 

[DreamMachine]

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