airway case

[cleansocks]

Hola,

In a few days I'll have the following case:

Lap adrenalectomy (presumed mets from RCC) for dude with propensity for cancer development. Years ago had radiation to the neck and big neck dissection for oral cancer. Anesthetic records in 2009 and 2010 each have a similar airway story: multiple attempts at awake fiberoptic failed, subsequently intubated blind. I believe blind nasal on the second one (2010) but the first one (2009) seems to indicate that despite trying a 5.5 ETT they couldn't pass it through the nares.

So far I'm thinking of trying the AFOI again just in case previous people sucked (unlikely), having ENT there, blind nasal as backup since it worked before - although I have little experience with this, and despite the running joke on these forums, maybe retrograde wire (?)... never done it before though.

What else should I be thinking about?

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[Wiscoblue]

Retrograde wire.

 

[k12balla]

I would try to gather more information on the prior failed attempts if it was done at your facility. Who did it, how was the patient prepped, and what exactly did they try and or see. Otherwise I wold agree with your plan AFOI, or if you have experience, retrograde wire, with smaller ETT, ENT as back up, possible awake trach.

 

[Planktonmd]

The fact they were able to intubate him blind twice means that there is a hole somewhere that someone was able to insert a tube through.
If there is hole then you should be able to do awake fiberoptic intubation and find that hole if you know how to properly anesthetize the airway.

 

[OB1🤙]

I may actually try an awake Glidescope. You may see nothing, you may see everything. Would be very gentle, obviously. Would proceed to fiber if that was obviously futile.

 

[Noyac]

Retrograde wire.

Bingo

Be sure to do a transtracheal as well.

 

[deleted162650]

Consider awake nasal FOI since things seem to line up better that way on the 2 previous occasions.

 

[cleansocks]

Good advice.

Anyone have any super fancy tricks or pearls of infinite wisdom for the less commonly done airway maneuvers like retrograde wires or blind nasals?

 

[Noyac]

Consider awake nasal FOI since things seem to line up better that way on the 2 previous occasions.

This is my approach if the airway seems overly difficult for this very reason.

 

[Noyac]

Good advice.

Anyone have any super fancy tricks or pearls of infinite wisdom for the less commonly done airway maneuvers like retrograde wires or blind nasals?

Blind nasals are very difficult if they are not breathing spontaneously.

 

[PianoMedic]

A few of my paramedic classmates did awake nasal intubations in the field. They used something they called a whistle that they attached onto the end of the ETT. I doubt that hospitals routinely carry them, and since your case is in a couple days probably no time to order one. Also, sitting and spontaneously breathing apparently helps with a blind nasal as well. Here is the link for a whistle, not sure how useful they are:
https://www.mooremedical.com/index....PG=CTL&CS=HOM&FN=ProductDetail&PID=5756&spx=1

 

[Agast]

Any chance this could be done under epidural, or is that just craziness?

 

[deleted171991]

Any chance this could be done under epidural, or is that just craziness?

Not if laparoscopic.

 

[pd4emergence]

I love an awake glidescope/cmac with fiber optic scope. Transtracheal, inhaled lidocaine, then get them to gargle some viscous lidocaine. Most failed awake techniques fail because of inadequate topicalization and/or sedation. Precedex for awakes is the best. I love that stuff.

 

[Planktonmd]

Blind nasals are very difficult if they are not breathing spontaneously.

Correct!

 

[Planktonmd]

I love an awake glidescope/cmac with fiber optic scope. Transtracheal, inhaled lidocaine, then get them to gargle some viscous lidocaine. Most failed awake techniques fail because of inadequate topicalization and/or sedation. Precedex for awakes is the best. I love that stuff.

If the patient is cooperative you don't need any sedation for an awake intubation

 

[Agast]

Do we know anything about being able to mask ventilate the patient?

 

[urge]

Not if laparoscopic.

It can be done. It was done once during my residency. It was smooth until the pt started vomiting. Then it wasn't so smooth.

There are many case reports about it.

 

[nap$ter]

Do we know anything about being able to mask ventilate the patient?

this should be question number 1.

patients s/p head/neck radiation can be surprisingly difficult to mask. relatively normal appearing anatomy can have the consistency and flexibility of wood.

burn bridges not.

 

[urge]

patients s/p head/neck radiation can be surprisingly difficult to mask. relatively normal appearing anatomy can have the consistency and flexibility of wood.

True. They tend to be easy fiberoptics. It's like intubating a mannequin.

 

[Orin]

I love an awake glidescope/cmac with fiber optic scope. Transtracheal, inhaled lidocaine, then get them to gargle some viscous lidocaine.

Yeah, the combined approaches are my favorite for truly difficult cases.

Topicalize with the gargled and nebulized lidocaine and taking an awake look with a video laryngoscope. Use the fiberoptic scope then like a guidable malleable bougie/introducer. Topicalize the cords through the scope with an epidural catheter if the working channel allows or just spray through it.

The irradiated tissue just doesn't move well with laryngoscopy, so you may still not get a view with the glidescope, but the combination of glidescope and fiberoptic visualization seems to suffice.

The other thing I hate is using those smaller scopes because the larger ones won't fit a 5.5 ETT or even if it fits, it is a pain to slide off/make turns/etc.

 

[Planktonmd]

Yeah, the combined approaches are my favorite for truly difficult cases.

Topicalize with the gargled and nebulized lidocaine and taking an awake look with a video laryngoscope. Use the fiberoptic scope then like a guidable malleable bougie/introducer. Topicalize the cords through the scope with an epidural catheter if the working channel allows or just spray through it.

The irradiated tissue just doesn't move well with laryngoscopy, so you may still not get a view with the glidescope, but the combination of glidescope and fiberoptic visualization seems to suffice.

The other thing I hate is using those smaller scopes because the larger ones won't fit a 5.5 ETT or even if it fits, it is a pain to slide off/make turns/etc.

I never understood why would anyone take a fantastic instrument like a fiberoptic scope and use it as a bougie!
It's like taking an expensive string instrument and banging on it like a drum!
Why not just use it the way it was intended to be used?

 

[pd4emergence]

If the patient is cooperative you don't need any sedation for an awake intubation

I'll be honest, I like my awake FOI's about how Bill Cosby likes his women…….sleepy

 

[pd4emergence]

I never understood why would anyone take a fantastic instrument like a fiberoptic scope and use it as a bougie!
It's like taking an expensive string instrument and banging on it like a drum!
Why not just use it the way it was intended to be used?

Because drums are easier to play…..

 

[Planktonmd]

Because drums are easier to play…..

Then either use a drum or learn how to play string!

 

[Orin]

Then either use a drum or learn how to play string!

But they only let me play string on the second blue moons in leap years...

 

[Agast]

*bump* How'd the patient do??

 

[cleansocks]

As interesting as a retrograde wire sounds, I kept hearing that it can be a nightmarish pain in the glutes.

So when the patient got to PACU I just tried a little afrin and inhaled lido and took a look with a peds scope while the patient was still in preop. I was able to wiggle it through the nasal passage to the glottis without irritating the patient and there seemed to be a decent amount of room.

So I proceeded with the completion of a typical awake nasal fiberoptic numbing extravaganza with progressively larger viscous lido'd nasal airways, viscous lido swabs against the tonsillar pillars, viscous lido's big red oral airway, atomizer while holding the tongue with a gauze, etc, etc, etc. Glad I didn't cause lidocaine toxicity!

It was a very smooth AFOI. Rather anticlimactic.

 

[ranvier]

Nice job. Good preparation (the toplicalization and review of previous records)!

 

[BLADEMDA]

 

[cleansocks]

So here's a fun question everyone has probably thought about. What would you use in the field if you wanted to cric someone without any of your usual supplies? Stabilize their neck in one hand, rip out the ink cartridge of a bic ballpoint with your teeth and jam it in like the movies? I will link a video for inspiration