Airway Topicalization

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
soorg

soorg

Board-certified maniac
Verified Member
15+ Year Member
Joined
Aug 7, 2008
Messages
210
Reaction score
143
Members do not see this ad.
How do y'all topicalize the airway for an awake FOB? I'm not a really big fan of sticking needles into people's necks, and I've seen people do it topically, with varied success...
 
soorg said:
How do y'all topicalize the airway for an awake FOB? I'm not a really big fan of sticking needles into people's necks, and I've seen people do it topically, with varied success...
Click to expand...

Aerosolized lidocaine works well, among other things.
 
Great question because there are so many ways and everyone insists theirs is the best. I never due SLN blocks for supraglottic anesthesia. It's not as reliable as aerosolizing lidocaine. There also always seems to be too much fat between me and the greater cornus'. Infraglottic I go transtracheal and I think the results are fantastic.

A corollary to this is what LA do you use? I use 1% above and 4% below and that keeps me well under toxic doses. I've been told 4% isn't as good because it doesn't aerosolize as well. Thoughts?

I've seen methemoglobinemia more than once from benzocaine spray and won't touch the stuff. I've done the LA through the scope and agree that it works well. That's what the pulmonologists do ain't it?
 
I like lido 2% jelly, on oral or nasal airway. I also like doing transtracheal as a way to 1) improve the topicalization and 2) practice doing a crich. Agree with the lido through the FOB but not all of our scopes can do it.
 
jwk said:
Aerosolized lidocaine works well, among other things.
Click to expand...

I'm a big fan of this.

Used to go exclusive with sticking needles everywhere before fiberoptic intubation....

Now I hav'em smoke the nebulized lidocaine peace pipe while I go take a whiz, come back and do a transtracheal (one stick as opposed to previous three),

and I'm done.😀
 
proman said:
I like lido 2% jelly, on oral or nasal airway. I also like doing transtracheal as a way to 1) improve the topicalization and 2) practice doing a crich. Agree with the lido through the FOB but not all of our scopes can do it.
Click to expand...

Resident colleagues,

please read what I've Jetted (hahahaha....my new term for the bold fonts dear to my heart) in Proman's post....

VERY IMPORTANT LEARNING OPPORTUNITY readily available to you.

Please follow Proman's lead and keep yourself proficient at cannulating the cricothyroid membrane....chances are the time WILL eventually come....may be five years.....maybe ten..... when you gotta step up to the mike with micatin and jet ventilate thru a deftly placed 14/16 gauge angio while everyone else is s h i tting their panties.

If you havent practiced hitting the cricothyroid with a needle recently you'll be putting snickers bars in your Hanes like everyone else when the patient needs your deftness the most!

Nice teaching point, Pro. Thanks.👍
 
I've found that the key to good topicalization is drying the hell out of the oropharynx. Glyco is helpful, then I usually have them breathe deeply in and out of their mouth or do the "pant like a dog" thing until they feel like their throat get really dry. Using that and the transtracheal usually gets em numbed up within 5-10 minutes easily. My local of choice is 4% lido. Ive also tried variations like mixing glyco in with the lido. One attending of mine used to swear by it. I never really saw a huge difference.
 
I have had the aerosolized lido fail b/4 but it is usually reliable.
My person preference is a cup of viscous Lido swish and swallow. I have them try to hold it in their mouth as long as possible b/4 swallowing it. Then I do a transtracheal with 2-3 cc 4% Lido. Bingo, done.
I rarely give glyco (which may be the reason my aeresolized lido failed) b/c the viscous lido doesn't need a dry mouth to work.
 
JetProp, your method sounds simplest. It really works well? I've only done about 4 of these durings residency, half with blocks, have with topicalization. Now that I'm an attending, I want to settle in on a method that works well consistently. Don't want some surgeon giving me the evil eye while his unstable c-spine patient is in buck-city...
 
soorg said:
JetProp, your method sounds simplest. It really works well? I've only done about 4 of these durings residency, half with blocks, have with topicalization. Now that I'm an attending, I want to settle in on a method that works well consistently. Don't want some surgeon giving me the evil eye while his unstable c-spine patient is in buck-city...
Click to expand...

😱
 
soorg said:
JetProp, your method sounds simplest. It really works well? I've only done about 4 of these durings residency, half with blocks, have with topicalization. Now that I'm an attending, I want to settle in on a method that works well consistently. Don't want some surgeon giving me the evil eye while his unstable c-spine patient is in buck-city...
Click to expand...

sometimes they just gotta accept some bucking. Most topicalizations require a semi-ccoperative pt which alot of these unstable cspine traumas arent. Now for an elective cervical fusion, topicalization or blocks of any kind work great, but you gotta realize that the transtracheal causes em to buck and cough too. If its a purely elective case and they look like an easy mask, it might be worth it to just mask em down and asleep fiberoptic. Otherwise something you do has a chance to make them buck.
 
Noyac said:
I have had the aerosolized lido fail b/4 but it is usually reliable.
My person preference is a cup of viscous Lido swish and swallow. I have them try to hold it in their mouth as long as possible b/4 swallowing it. Then I do a transtracheal with 2-3 cc 4% Lido. Bingo, done.
I rarely give glyco (which may be the reason my aeresolized lido failed) b/c the viscous lido doesn't need a dry mouth to work.
Click to expand...

I give glyco, Noy, to reduce the spit for when its time for the scope.

I think it makes a difference.
 
jetproppilot said:
I give glyco, Noy, to reduce the spit for when its time for the scope.

I think it makes a difference.
Click to expand...

Yeah, I know that most people give is for the secretions. I just don't usually have trouble with this. I was refering to someones statement that the glyco helped with topicalization.
 
huktonfonix said:
sometimes they just gotta accept some bucking. Most topicalizations require a semi-ccoperative pt which alot of these unstable cspine traumas arent. Now for an elective cervical fusion, topicalization or blocks of any kind work great, but you gotta realize that the transtracheal causes em to buck and cough too. If its a purely elective case and they look like an easy mask, it might be worth it to just mask em down and asleep fiberoptic. Otherwise something you do has a chance to make them buck.
Click to expand...

For this reason I don't usually do a transtracheal in an unstable cervical fx. This is were I would do a nebulized Lido and add some viscous lido if not completely numb. But the neb will hopefully topicalize the trachea as well.
 
Noyac said:
For this reason I don't usually do a transtracheal in an unstable cervical fx. This is were I would do a nebulized Lido and add some viscous lido if not completely numb. But the neb will hopefully topicalize the trachea as well.
Click to expand...

Funny how two completely deft dudes can think unalike in this biz!

I think the transtracheal lido is very important in any fiberoptic intubation.

I'd use it especially in a sphincter case like an unstable cervical fracture that requires a scope for intubation.
 
There is really no perfect method that works every time.
I use Glyco always.
I recently stopped doing superior laryngeal blocks and started depending more on nebulized Lidocaine 4% with very good results.
I also use an atomizer attached to a syringe with Lido 4% as well.
I still do transtracheal blocks if I can.
I only use Lido 4% because I think it does work better on the mucosa.
I frequently run a Remifentanyl infusion for awake intubations and I think it makes your topical anesthesia more effective.
 
Planktonmd said:
There is really no perfect method that works every time.
I use Glyco always.
I recently stopped doing superior laryngeal blocks and started depending more on nebulized Lidocaine 4% with very good results.
I also use an atomizer attached to a syringe with Lido 4% as well.
I still do transtracheal blocks if I can.
I only use Lido 4% because I think it does work better on the mucosa.
I frequently run a Remifentanyl infusion for awake intubations and I think it makes your topical anesthesia more effective.
Click to expand...

DEX is better in this situation in my humble opinion.
 
jetproppilot said:
DEX is better in this situation in my humble opinion.
Click to expand...

Dex is good but I gave a very large dose to a young guy with a horrendous airway due to cancer and necrosis with no effect. I moved to propofol. Never seen it since and never saw it b/4 but it impressed the hell out of me. The guy had a drug history as well if that makes any difference.
 
Noyac said:
Dex is good but I gave a very large dose to a young guy with a horrendous airway due to cancer and necrosis with no effect. I moved to propofol. Never seen it since and never saw it b/4 but it impressed the hell out of me. The guy had a drug history as well if that makes any difference.
Click to expand...

Thats interesting and unexpected.

I'dve thought dex wouldve been a good choice on a drug user.

Did propofol work on the dude?
 
Plank,

Ever seen muscle rigidity with a remi infusion as you describe? Nasty, nasty thing. I'm with Jet on the Precedex for the application you describe.

-copro
 
coprolalia said:
Plank,

Ever seen muscle rigidity with a remi infusion as you describe? Nasty, nasty thing. I'm with Jet on the Precedex for the application you describe.

-copro
Click to expand...
Remifentanyl at the right dose effectively attenuates the cough reflexes and improves patient comfort while maintaining consciousness and since it has an ultra short half life it can be stopped and allows you to bail out if you need to.
Muscle rigidity caused by narcotics is a questionable entity and many people now attribute it to upper airway obstruction and laryngospasm rather than the true muscle rigidity that we used to be taught in the past. (look it up).
You can use any drug you like as long as you keep the patient "awake" which means following command and as long as you do that I guarantee you that you will not have the airway obstruction that the elders of anesthesiology used to call "muscle rigidity".
Not that I am calling you an elder 🙂
 
Okay, I'll bite... what's the "right dose" for any given patient?

And, call it whatever you want, I've seen it. It's friggin' scary.

-copro
 
coprolalia said:
Okay, I'll bite... what's the "right dose" for any given patient?

And, call it whatever you want, I've seen it. It's friggin' scary.

-copro
Click to expand...
The "right dose" of any anesthetic is the dose that can give you the desired effect with minimum side effects.
The way you find the right dose: you titrate from a small dose.
For Remi I would start at something like 0.05mcg/kg/min and go from there, you rarely have to go above 0.15 mcg/kg/min.
Remember the goal is to keep the patient awake but improve tolerance to airway manipulation.
Notice that I am not saying that this is the best way or the only way, I am just saying that it is " a way" that I use.
 
I think it was more prevalent back in the days of slower acting muscle relaxant and higher doses of opiods given at induction.
If you give your muscle relaxant early enough then you just don't see this vocal chord closure/"thoracic rigidity".

Upper airway closure: a primary source of difficult ventilation with sufentanil induction of anesthesia.

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


Anesthesiology. 1991 Dec;75(6):969-74.Links
Ventilatory compliance after three sufentanil-pancuronium induction sequences:

"All groups achieved similar total compliances several minutes after a total of 100 micrograms.kg-1 pancuronium had been administered."
 
Last edited:
If you look at the literature there is no objective measurement of chest wall compliance although this pseudo phenomenon is very easy to create.
I say BS the objective studies are the ones that i've cited, if anybody can find some evidence behind this DOGMA please post it.
 
Noyac said:
I've seen it. It's real and it sucks. I am under the impression it is more common in the young healthy strong bucks but not at all limited to these guys. It can only be treated with sux/muscle relaxant (well and possibly severe hypoxia).
Click to expand...

JEFF PISTO saw it too!:laugh:

I posted about that hilarious scenario that occurred during our residency.
 
I saw it once during a reminfentanil "induction", and the only out was sux/tube (which, fortunately, was where we were going anyway).

Had remi and Precdex infusing before a TIVA (my attending wanted it to be a pure TIVA... using only the drugs in the TIVA mix: propofol, remi, and Precedex) for a intravascular cerebral coiling. So, we started the infusions to get a "head start" and then planned on sux and propofol boluses before the tube.

I'd probably done this exact same technique (up to this point) at least a dozen times before. I started the infusions, was talking to the lady, and was letting her breathe from the mask resting on her face. I turned away for less than ten seconds (literally) to grab my tube and my bolus meds. I turned back, and noticed that she was stiff as a board. Thin, little 60-something woman with an easy airway. I tried to BMV her, to no avail. She started to de-sat. Prop, sux, tube after that.

Made me pucker, I tell you. Couldn't bag mask. Lady was stiff as a board. So, might be ascribed to an "upper airway" thing, but I'll tell you what I saw was that her whole body was rigid.

-copro
 
Last edited:
I don't know if it is chest wall rigidity or just airway obstruction and cords closure (which I tend to think is the case now) but I have seen it a few times when we used to do high dose narcotic induction.
 
Planktonmd said:
I don't know if it is chest wall rigidity or just airway obstruction and cords closure (which I tend to think is the case now) but I have seen it a few times when we used to do high dose narcotic induction.
Click to expand...

Hasn't it always been described as chest wall rigidity?
 
jetproppilot said:
DEX is better in this situation in my humble opinion.
Click to expand...


I have used dex and it worked well. I have not used the transtrach method during awake FOB. Can anyone tell me how they go about performing the transtrach leg of this.

Cambie
 
jetproppilot said:
I think the transtracheal lido is very important in any fiberoptic intubation.
Click to expand...

How do you like to do your transtracheal injections?

I've been taught to put the lido syringe on the back of a 20g angiocath (the old school kind, not the safety ones), stab the neck, aspirate for bubbles, slide the angiocath off into the trachea, connect the syringe to the angiocath and inject 2 cc of 4%, and leave the angiocath in until the ETT is taped. The idea being that if everything goes to hell you have an angiocath in the trachea already for jet ventilation or a retrograde wire.

It has always worked for me, but I'm not 100% satisfied with it. Extra steps take time and are opportunities for problems with the angiocath going off course or kinking or getting hung up; I'm skeptical that jet ventilation through a 20g would really work; the catheter is aimed caudad so the retrograde wire hail mary seems destined to fail. Twice recently I've just used an ordinary 20g needle and injected after the bubbles tell me I'm in the right place. (Immediately followed up by staff correction that I should have used the angiocath technique.)

I'm losin' faith in the angiocath method and leaning toward the simple needle stab despite what I've been taught.
 
a couple of things. A 20g will be inadequate for jet ventilation, but it will allow you to exchange for a bigger cath if you need. Also, if the cath is pointed caudad you may not be getting the right area anesthetized. When, I trained we always did the needle stab. I suppose a possible advantage with the catheter is that you dont have something sharp in the trachea when they cough, although I havent heard of any problems with this so far. I personally still do the needle stab and go back with a catheter if I think I'll need it or finding the cricothyroid membrane was in any way difficult
 
CambieMD said:
I have used dex and it worked well. I have not used the transtrach method during awake FOB. Can anyone tell me how they go about performing the transtrach leg of this.

Cambie
Click to expand...

Stick a 20G needle or an angiocatheter (I prefer the angiocatheter) in the cricothyroid membrane, aspirate air, pull needle out (if you are using angio) attach syringe to angiocatheter and inject 4cc Lido 4%.
Patient will cough and spray local toward the vocal cords.
 
You must log in or register to reply here.

Similar threads

C
Manage this TikTok airway
Replies
20
Views
2K
patriot6
patriot6
D
Airway bubble?
Replies
0
Views
866
deleted875186
D
epidural man
Peds airway foreign body
Replies
26
Views
2K
epidural man
epidural man
S
Oral airways in pacu
Replies
32
Views
4K
PpfSuxTube
P
bbc586
Surgical Airway Complications [Medical Malpractice Lawsuit]
2
Replies
55
Views
5K
VisionaryTics
VisionaryTics
Top