Airway Case

[TheComebacKid]

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Solid strategy.

I was always a big proponent of the nasal trumpet as well, but one thing that we've been playing with and found effective (I'm in academics) is actually pre-placing the endotracheal tube.

So instead of placing the nasal trumpet in the nare, you actually just gently place the 6-0 endotracheal tube blindly until you are passed the turbinates. The tip of the balloon will then be in the nasopharynx but still well above the cords - where the end of your nasal trumpet would usually be. You then use this as the conduit to pass your fiberoptic without picking up mucus on the turbinates, and when the fiberoptic is through the cords you can then just advance the ETT the rest of the way. This eliminates the step of removing the nasal trumpet (easy enough with the pre-cutting, but still), as well as that unfortunate situation where your fiberoptic is through the cords but the ETT won't get through the turbinates

Food for thought my friends.

Excellent.

I don't know if there are any studies on this, but anecdotally it seems like this should be the standard of care in the ED. The vast majority of people who I have seen struggle with these (including ENT) is because the patient has huge turbinates and they can't navigate through the nasal cavity without getting fogged/misted or boogered up.

While I haven't encountered it personally on the two patient's I've done it on, I have noticed others really struggle to pass the tube through the nasal cavity despite ample lubrication. Your method could very realistically help avoid this complication.

I'm convinced by using this method, you really have to have absolutely minimal training with fiberoptic scopes and you can still manage the difficult airway.

 

[Southpaw]

Solid strategy.

I was always a big proponent of the nasal trumpet as well, but one thing that we've been playing with and found effective (I'm in academics) is actually pre-placing the endotracheal tube.

So instead of placing the nasal trumpet in the nare, you actually just gently place the 6-0 endotracheal tube blindly until you are passed the turbinates. The tip of the balloon will then be in the nasopharynx but still well above the cords - where the end of your nasal trumpet would usually be. You then use this as the conduit to pass your fiberoptic without picking up mucus on the turbinates, and when the fiberoptic is through the cords you can then just advance the ETT the rest of the way. This eliminates the step of removing the nasal trumpet (easy enough with the pre-cutting, but still), as well as that unfortunate situation where your fiberoptic is through the cords but the ETT won't get through the turbinates

Food for thought my friends.

Anesthesia here. Sorry that @Groove has poor anesthesia coverage. Nothing wrong with blindly passing 6.0 during nasal AFOI to get past turbinates as long as you stop with resistance. I occasionally do that in airways that I don't believe are going to be horrendous. I have colleagues that use it as their standard for nasal AFOI. If you don't stop and readjust, or just come out completely and change your plan, you'll stir up bleeding in the exact airway that doesn't need it. Honestly it's not that tough to get past the turbinates with a fiberoptic scope.

With regards to the case, I'm glad it worked out well. I have to say though that the obstruction seemed clearly subglottic based on presentation. The airway seemed to be begging for AFOI. Your patient was small, old, edentulous, tachypneic, and in distress with a stridor and a gigantic goiter. You didn't gain anything with the glide scope. She was going to provide an easy view of the glottic opening regardless of what you did. You could've done DL with bougie with same result. The problem was always going to be what lies beneath. You figured it out and was successful but I wouldn't have been surprised in the least that given your plan you ended with a slash trach that turned into a bleeding disaster. You may not be happy with my opinion, but medical students and residents read this forum to learn, so I feel obliged to render my opinion. Regardless, you had success and I'm glad for your patient. I hope they're well.

P.S. If you want to pass the tube first with awake nasal FOI, dilate the nasal cavity with increasingly large nasopharyngeal airways lubed with lidocaine jelly after first spraying the nose with oxymetazoline a few times. Good luck.

 

[Groove]

Anesthesia here. Sorry that @Groove has poor anesthesia coverage. Nothing wrong with blindly passing 6.0 during nasal AFOI to get past turbinates as long as you stop with resistance. I occasionally do that in airways that I don't believe are going to be horrendous. I have colleagues that use it as their standard for nasal AFOI. If you don't stop and readjust, or just come out completely and change your plan, you'll stir up bleeding in the exact airway that doesn't need it. Honestly it's not that tough to get past the turbinates with a fiberoptic scope.

With regards to the case, I'm glad it worked out well. I have to say though that the obstruction seemed clearly subglottic based on presentation. The airway seemed to be begging for AFOI. Your patient was small, old, edentulous, tachypneic, and in distress with a stridor and a gigantic goiter. You didn't gain anything with the glide scope. She was going to provide an easy view of the glottic opening regardless of what you did. You could've done DL with bougie with same result. The problem was always going to be what lies beneath. You figured it out and was successful but I wouldn't have been surprised in the least that given your plan you ended with a slash trach that turned into a bleeding disaster. You may not be happy with my opinion, but medical students and residents read this forum to learn, so I feel obliged to render my opinion. Regardless, you had success and I'm glad for your patient. I hope they're well.

P.S. If you want to pass the tube first with awake nasal FOI, dilate the nasal cavity with increasingly large nasopharyngeal airways lubed with lidocaine jelly after first spraying the nose with oxymetazoline a few times. Good luck.

In this particular case, it may sound convincingly subglottic but it wasn't, at least to me, convincing at the time. Remember there were two of us. The two operator approach with VL and Bronch I actually learned from an anesthesiologist talking about potential approaches to angioedema. The benefit is that you have an operator using video laryngoscopy to maximize your view and provide assistance in navigating the end of the bronchoscope to the cords and decreasing your time. I don't have to worry about navigating the nasopharynx or causing bleeding that would further obscure my view. I wasn't sure what we would find. In hindsight, I agree that FOI after the tube wouldn't pass through the cords would have been preferred over bougie through the ETT but the ETT was already at the cords and I rationalized that if we could pass it gently with no resistance then a mass or severe obstructing stenotic lesion was less likely. The bougie passed so easily I was willing to risk it and raised doubts that it was subglottic but I agree....if I had it to do over I prob would have withdrawn ETT and used fiber to see what was below the cords before pushing the ETT. I will say that with the amount of manipulation that I had to use to get the 6.5 down, I'm doubtful that I would have been able to pass it easily nasotracheal. 6.0? Maybe...but I didn't have a 6.0. How long are your 6.0 tubes? I've had to hub my 6.5 out at the nare for an adult nasotracheal intubation.

Thanks for the input. Always appreciate other perspectives.

 

[Groove]

Yes. It's topical, so there's not going to be any harms with precipitation.

This. I checked with respiratory and pharmacy tonight. I think the utility of mixing them together would be low though.

 

[Southpaw]

In this particular case, it may sound convincingly subglottic but it wasn't, at least to me, convincing at the time. Remember there were two of us. The two operator approach with VL and Bronch I actually learned from an anesthesiologist talking about potential approaches to angioedema. The benefit is that you have an operator using video laryngoscopy to maximize your view and provide assistance in navigating the end of the bronchoscope to the cords and decreasing your time. I don't have to worry about navigating the nasopharynx or causing bleeding that would further obscure my view. I wasn't sure what we would find. In hindsight, I agree that FOI after the tube wouldn't pass through the cords would have been preferred over bougie through the ETT but the ETT was already at the cords and I rationalized that if we could pass it gently with no resistance then a mass or severe obstructing stenotic lesion was less likely. The bougie passed so easily I was willing to risk it and raised doubts that it was subglottic but I agree....if I had it to do over I prob would have withdrawn ETT and used fiber to see what was below the cords before pushing the ETT. I will say that with the amount of manipulation that I had to use to get the 6.5 down, I'm doubtful that I would have been able to pass it easily nasotracheal. 6.0? Maybe...but I didn't have a 6.0. How long are your 6.0 tubes? I've had to hub my 6.5 out at the nare for an adult nasotracheal intubation.

Thanks for the input. Always appreciate other perspectives.

I wasn't trying to be critical. You were there and obviously took great care of your patient. You got it done. If you're planning nasal you'd want a nasal ETT to give you the length you'd need.

 

[Groove]

Solid strategy.

I was always a big proponent of the nasal trumpet as well, but one thing that we've been playing with and found effective (I'm in academics) is actually pre-placing the endotracheal tube.

So instead of placing the nasal trumpet in the nare, you actually just gently place the 6-0 endotracheal tube blindly until you are passed the turbinates. The tip of the balloon will then be in the nasopharynx but still well above the cords - where the end of your nasal trumpet would usually be. You then use this as the conduit to pass your fiberoptic without picking up mucus on the turbinates, and when the fiberoptic is through the cords you can then just advance the ETT the rest of the way. This eliminates the step of removing the nasal trumpet (easy enough with the pre-cutting, but still), as well as that unfortunate situation where your fiberoptic is through the cords but the ETT won't get through the turbinates

Food for thought my friends.

Hmm, you're talking about placing the ETT through the nasopharynx before passing the bronch. Isn't this standard nasotracheal intubating procedure? You dilate up to be able to pass the ETT through easily. Optimal depth is about 15cm. You'll find it much easier to navigate to the cords. If the end is closer to the nasopharynx it's really easy to get lost, at least for me. If you are at 15cm you don't have far to navigate. Epiglottis should be right in front of you.

One idea I've toyed with (for nasotracheal AFOI) but haven't tried (it's not like we have a chance to do these very often) is having an assistant stand in front of the pt sitting up and use a laryngoscope blade to maximize the oropharyngeal space while I attempted AFOI nasotracheal. It seems to me that would make navigating the oropharynx easier...

 

[Groove]

To clarify my above post, the trumpets are super squishy and malleable but still cause pressure on the sinus which helps dilate. The ETT is much more stiff and you have a higher chance of traumatizing the sinuses if you push too hard in a non dilated sinus. Even just a little bit of bleeding will totally f'up your view. If you're using an ambuascope which already has sh**ty suction, forget about it.

I empty out half a bottle of afrin, draw up syringe full of 4% lido and squirt it through the atomizing hole for 1:1. Shake it up and squirt that up their sinuses. Great analgesia and vasoconstriction. I picked that one up from an ENT. Works great. Viscous lido for the trumpets.

 

[Hamhock]

This. I checked with respiratory and pharmacy tonight. I think the utility of mixing them together would be low though.

Thanks for checking. I am back in the hospital today and was going to do the same, but you beat me to it.

Regarding the utility: wouldn't this save time? Treatments in parallel always seem more efficient to me that treatments in series.

HH

 

[Groove]

Thanks for checking. I am back in the hospital today and was going to do the same, but you beat me to it.

Regarding the utility: wouldn't this save time? Treatments in parallel always seem more efficient to me that treatments in series.

HH

You know I've never really thought about it honestly. I guess what I meant to say is that there shouldn't be any synergy in mixing the two though you've got a point in that it technically saves some time. Hell, I don't see any harm. Why not?

 

[FirstNobleTruth]

Hmm, you're talking about placing the ETT through the nasopharynx before passing the bronch. Isn't this standard nasotracheal intubating procedure? You dilate up to be able to pass the ETT through easily. Optimal depth is about 15cm. You'll find it much easier to navigate to the cords. If the end is closer to the nasopharynx it's really easy to get lost, at least for me. If you are at 15cm you don't have far to navigate. Epiglottis should be right in front of you.

One idea I've toyed with (for nasotracheal AFOI) but haven't tried (it's not like we have a chance to do these very often) is having an assistant stand in front of the pt sitting up and use a laryngoscope blade to maximize the oropharyngeal space while I attempted AFOI nasotracheal. It seems to me that would make navigating the oropharynx easier...

Yup, exactly. I also recommend serial dilation with the NPA's as necessary. The initial post I was responding to was describing a technique where you would use a NPA to pass the fiberoptic through, but then have to have a method to remove that NPA in order to pass the ETT. Using the ETT to do this skips a step.

 

[Noyac]

Agreed. To each his own. I did generalize a bit. I am happy to help a colleague learn a new skill, just not when it's emergent, time-sensitive with potential for dire consequences if they are unsuccessful. There's also an element for respect for other people's time. I'm not generally at work, sitting around doing nothing. Being called away from the OR to the ED for an airway is fine; that's part of my job. The OR (or OB or ICU or whatever) can wait if I'm attending to an emergency elsewhere. But if I put the OR on hold (stop seeing patients, stop taking patients back, stop doing labor epidurals, make surgeons wait, etc) it's generally not going to be for a teaching session. In residency, I learned to do fiberoptic bronchoscopy either bronching in the ICU or doing elective asleep fiberoptic intubations in the OR. I had many elective, easy, fiberoptic intubations under my belt before I ever tried an awake, emergent or difficult one. Personally, I'd recommend asking anesthesia about doing elective asleep fiberoptics in the OR. I'd be happy to accommodate that. Also, it makes the time commitment yours rather than some random person you may or may not know who has a bunch of other stuff to do.

thats a better post. The one leading up to this was too dogmatic for me. My assumption was that he/she wanted to practice on an elective. Maybe I was wrong.