Awake fiberoptic intubation oral airways

[Sonny Crocket]

Just wondering if you guys always use either the williams, ovasapian, or berman(sp?) when doing awake FOI. I have always used the williams or berman. I've never even tried without. I guess once you get your technique that works you tend to stick with it. Saw some vids on youtube where they did not use any airway and beginning to wonder if the airway is necessary.

One of the reasons I use it is because I feel that if they can tolerate the airway, than I've done a good job topicalizing the oropharynx.

Sonny

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[B-Bone]

I don't use one. Just have somebody grab the tongue with a 4x4 (or a towel clip if you're a dick).

 

[fakin' the funk]

Saw some vids on youtube where they did not use any airway and beginning to wonder if the airway is necessary.

One of the reasons I use it is because I feel that if they can tolerate the airway, than I've done a good job topicalizing the oropharynx.

The oral airway is certainly not necessary per se (to place the ETT), and yes it can give you some info about how well the OP is topicalized, but so can poking the posterior OP with your atomizer or tongue depressor.

Personally I think the oral airway doesn't provide additional help guiding you to the glottis (the genioglossus has tone awake so you don't need external anterior traction on the tongue) and adds an extra step where you can dislodge the ETT when you're removing the airway. I go without and do fine.

 

[cchoukal]

I trained under Dr. Ovassapian, and so I use his airway exclusively. I tried the Berman at my new institution, and I still prefer the Ovassapian for the following reasons:

It's flat so it seems to stay in position better.
The flat, long blade of it works well for the additional application of lidocaine ointment
Once the tube is in and it's time to remove the airway, the Ovassapian is much easier to break away from the ETT compared to the Berman.


Is ANY airway necessary? For patients with redundant tissue, having the airway provides a nice white/pink border to help orient me. That and preventing the patient from biting through the scope, although if your AFOI patient is biting down, you're already well down the rabbit hole.

 

[Mman]

I use the ovassapian if I'm doing oral awake FOI. But I try really hard to go nasal and need a go reason not to. Much easier IMHO.

 

[rsgillmd]

Just wondering if you guys always use either the williams, ovasapian, or berman(sp?) when doing awake FOI. I have always used the williams or berman. I've never even tried without. I guess once you get your technique that works you tend to stick with it. Saw some vids on youtube where they did not use any airway and beginning to wonder if the airway is necessary.

One of the reasons I use it is because I feel that if they can tolerate the airway, than I've done a good job topicalizing the oropharynx.

Sonny

In residency we used the Ovassapian. I've tried the Williams -- it's OK. Never tried the Berman -- not even sure what it looks like. I've done without also, but I find the the airway useful in helping to keep the tongue out of the way. In my opinion, an airway is particularly useful for this purpose in people with redundant tissue.

I think airway vs no airway is like stylet vs no stylet in a way. Sure you don't need a stylet to intubate, but it does generally make things a little easier. Nobody is going to give you bonus points for taking the harder route.

 

[jetproppilot]

I don't use one. Just have somebody grab the tongue with a 4x4 (or a towel clip if you're a dick).

Cchoukal and others have corroborated the fact that

YOU DON'T NEED A SPECIALIZED AIRWAY AND

I agree.

I don't use one.

THREE ESSENTIAL THINGS TO OPTIMIZE A FIBEROPTIC INTUBATION:

1) An anesthetized airway.

However you wanna do it. Nerve blocks, nebulized lidocaine, whatever man. Anesthetize however you want, but GET IT DONE SO THE PATIENT'S GAG REFLEX MIMICS THAT OF A PORN STAR.

2) A DRY AIRWAY.

Nothing pisses you off more than having a great anesthetized airway

COCK BLOCKED by SPIT WHICH CLOUDS YOUR SCOPE and ruins visualization. Seems more ubiquitous in the obese patients which are more Orally Juicy for some reason unknown to me. Preoperatively give .4mg Robinol (I HATE using brand names to describe a drug, but I can't remember how to spell glycopyrrolate...btw is that right? Did I spell it right by luck?) to help make their airway Cow Paddy Dry.


3) TONGUE OUTTA THE WAY.


Yeah, a 4X4 on the tongue and a helper pulling it out of the mouth helps volumes.


NO PROPRIETARY AIRWAY NEEDED.

Follow these THREE STEPS and you'll be able to guide your scope, video game style, through those two white little Holy Grail things we refer to as

VOCAL CORDS.

 

[Mman]

3) TONGUE OUTTA THE WAY.


Yeah, a 4X4 on the tongue and a helper pulling it out of the mouth helps volumes.

Yeah, pulling on the tongue helps volumes. But patients tend to tolerate an oral airway better than they do somebody continually pulling their tongue out of their mouth.

 

[Sublimazing]

I've been leaving the airway in after AFOI, and I usually place one after my DL oral intubations ever since I had a pt bite on the tube and desat...is leaving it in there contraindicated?

 

[Planktonmd]

I had a patient once bite the Fiberoptic scope and break it!
So, since then I always use a Williams airway or if I don't find one I use the plastic bitebolck they use for upper endoscopy.

 

[fakin' the funk]

Cchoukal and others have corroborated the fact that

YOU DON'T NEED A SPECIALIZED AIRWAY AND

I agree.

I don't use one.

THREE ESSENTIAL THINGS TO OPTIMIZE A FIBEROPTIC INTUBATION:

1) An anesthetized airway.

However you wanna do it. Nerve blocks, nebulized lidocaine, whatever man. Anesthetize however you want, but GET IT DONE SO THE PATIENT'S GAG REFLEX MIMICS THAT OF A PORN STAR.

2) A DRY AIRWAY.

Nothing pisses you off more than having a great anesthetized airway

COCK BLOCKED by SPIT WHICH CLOUDS YOUR SCOPE and ruins visualization. Seems more ubiquitous in the obese patients which are more Orally Juicy for some reason unknown to me. Preoperatively give .4mg Robinol (I HATE using brand names to describe a drug, but I can't remember how to spell glycopyrrolate...btw is that right? Did I spell it right by luck?) to help make their airway Cow Paddy Dry.


3) TONGUE OUTTA THE WAY.


Yeah, a 4X4 on the tongue and a helper pulling it out of the mouth helps volumes.


NO PROPRIETARY AIRWAY NEEDED.

Follow these THREE STEPS and you'll be able to guide your scope, video game style, through those two white little Holy Grail things we refer to as

VOCAL CORDS.

This is going into a book? It's like Larry the Cable Guy's Guide to Anesthesia?

 

[jetproppilot]

This is going into a book? It's like Larry the Cable Guy's Guide to Anesthesia?

EXACTLY.

Ya see, down here in the south we need help with LEARNIN' cuz we be kinda simple minded so as such I likes to keep things ezey.

Hey Fake,

You happen to have a dip on ya??

 

[Planktonmd]

EXACTLY.

Ya see, down here in the south we need help with LEARNIN' cuz we be kinda simple minded so as such I likes to keep things ezey.

Hey Fake,

You happen to have a dip on ya??

I agree with all the pearls Jet stated... actually if you follow his simple (redneck) advice you will be successful doing slick fiberoptic intubations.
It's not rocket science but it requires a minimal level of skill that not every one has.

 

[Oggg]

In residency I saw one pt who had an oral airway in with an ETT and a OGT during surgery, and she developed necrosis of the uvula postop

 

[pgg]

I had a patient once bite the Fiberoptic scope and break it!

This is primarily why I put an airway. Patients can't be trusted and scopes are expensive. Dentists put in bite blocks for a reason, they need their fingers.



Agree with the rest. Topicalization and a dry airway are key and they take a little bit of time and planning. A rushed AFOI is a flail.

Also, minimal or even no sedation. (Since we're coming up on oral board season, I'll add that this was emphasized as a killing/failing error at my oral board review course: your sedated but still uncooperative or anxious patient undergoing AFOI is hypoxic/hypercarbic until proven otherwise. Choosing to sedate that patient further is the wrong move.)

 

[pgg]

In residency I saw one pt who had an oral airway in with an ETT and a OGT during surgery, and she developed necrosis of the uvula postop

I have seen this too (though it was necrosis of a part of the hard palate). I never leave something hard in the mouth during a case. Soft bite block goes in before emergence.