"Awake Fiberoptic" Intubation

[cchoukal]

65 yo M in pre-op for dental extraction planned for future implants. The usual comorbidities: morbid obesity, HTN, DM, OSA not using CPAP. His airway exam shows a thick neck, small mouth opening, big teeth, and a big tongue. Neck moves okay and he can sublet his mandible anterior to his maxillae teeth. Planned asleep glide until he says, "I was at the OSH having a cysto and they told me they had to wake me up to put the breathing tube in me. Whaddaya think that means, doc?"

I was able to pull up the records and, sure enough: multiple failed DL, failed VL, awoken (so assumed they could mask), and then did an "awake fiberoptic."

So my plan changed, but I do a fair number of sedated, topicalized fiberoptic intubations (I never call them awake; it freaks everyone out, and it's not even true).

I've written my routine here before, but, briefly:

Psychoprophylaxis
Glycopyrrolate
5% ointment to tongue in successive sweeps, each further back than the last.
Midazolam
to room

In the room, I keep them on the gurney, upright, monitors, NC oxygen.
4% lido spray to tonsils and over the top of the glottis
2% lido via transtracheal
Ovassapian Airway.

At this point, the patient is well-sedated and theoretically well-topicalized, but won’t tolerate the Ovassapian past the first couple inches.

I re-sprayed with more 4% and had him gargle. no change. 4% lido nebulizer. No change. More sedation, more 4% gargle, no change.

Oral surgeon humbly suggests maybe the nose. I reluctantly topicalized the L naris. couldn’t tolerate even the 30 nasopharyngeal airway despite aggressive topicalization.

So, is this lidocaine resistance? Certainly part of the tongue was numb, so probably not.

At this point, what’s your next move?

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[sethco]

Given previous airway management, one would think that the patient maintained easy ventilation during the multiple DL/VL attempts. Why not just go straight to asleep FOI instead of doing all this topicalization/sedation? My go to for the really difficult Intubation, while maintaining easy ventilation, is using both the VL and the FOB at the same time. Granted you need an extra set of hands and I only had to do this twice, but was amazed at how easy it was

 

[deleted126335]

65 yo M in pre-op for dental extraction planned for future implants. The usual comorbidities: morbid obesity, HTN, DM, OSA not using CPAP. His airway exam shows a thick neck, small mouth opening, big teeth, and a big tongue. Neck moves okay and he can sublet his mandible anterior to his maxillae teeth. Planned asleep glide until he says, "I was at the OSH having a cysto and they told me they had to wake me up to put the breathing tube in me. Whaddaya think that means, doc?"

I was able to pull up the records and, sure enough: multiple failed DL, failed VL, awoken (so assumed they could mask), and then did an "awake fiberoptic."

So my plan changed, but I do a fair number of sedated, topicalized fiberoptic intubations (I never call them awake; it freaks everyone out, and it's not even true).

I've written my routine here before, but, briefly:

Psychoprophylaxis
Glycopyrrolate
5% ointment to tongue in successive sweeps, each further back than the last.
Midazolam
to room

In the room, I keep them on the gurney, upright, monitors, NC oxygen.
4% lido spray to tonsils and over the top of the glottis
2% lido via transtracheal
Ovassapian Airway.

At this point, the patient is well-sedated and theoretically well-topicalized, but won’t tolerate the Ovassapian past the first couple inches.

I re-sprayed with more 4% and had him gargle. no change. 4% lido nebulizer. No change. More sedation, more 4% gargle, no change.

Oral surgeon humbly suggests maybe the nose. I reluctantly topicalized the L naris. couldn’t tolerate even the 30 nasopharyngeal airway despite aggressive topicalization.

So, is this lidocaine resistance? Certainly part of the tongue was numb, so probably not.

At this point, what’s your next move?

Skip the Ovassapian. Have pt stick out tongue and have assistant be prepared to gently hold tongue and pull forward if necessary. Rolled 4x4s as bite block to protect scope. Proceed with awake f.o.

 

[cchoukal]

Given previous airway management, one would think that the patient maintained easy ventilation during the multiple DL/VL attempts. Why not just go straight to asleep FOI instead of doing all this topicalization/sedation? My go to for the really difficult Intubation, while maintaining easy ventilation, is using both the VL and the FOB at the same time. Granted you need an extra set of hands and I only had to do this twice, but was amazed at how easy it was

I wanted to assume that MV would be possible. According to the OSH records (which, BTW, were from a real hospital with people I know and trust to be good), they gave succ, and part of the reason they "woke him up" after failing was that he'd resumed spontaneous ventilation on his own. Bottom line: he looked really difficult to mask, and I couldn't assume, based on what happened at the OSH, that it would be possible.

 

[chessknt]

I have encountered this in bronchs and procedures as well where I gives 3-4x the amount of lidocaine and people still gag or scream when I try to go and I usually just have to push past it.

I think to a large degree it is psychological because it is impossible to remove all sensation during a procedure and even the act of pressure and manipulation even away from sensitive areas. Since you have a stable patient maybe try more aggressive sedation—ketamine or propofol to improve tolerance with faith that the topicalization is fine and you just need the cns to stop extrapolating other sensory inputs you haven’t abolished.

 

[Noyac]

How much glyco?

 

[deleted875186]

What’s your sedation at this point?
What was the psychoprophylaxis?

I would probably try more fentanyl or Remi, assuming guy is awake, breathing, not obstructing, and your assessment at this point is that he won’t tolerate the scope. Prop I think is also reasonable in small doses. Ketamine maybe, but I don’t like the secretions, and I think opioid works better for what yojr trying to achieve.

 

[deleted697535]

Many ways to eat a cat. Most recently with covid etc ive just been doing midaz/remi, no lido at all and it goes fine.

 

[sethco]

I wanted to assume that MV would be possible. According to the OSH records (which, BTW, were from a real hospital with people I know and trust to be good), they gave succ, and part of the reason they "woke him up" after failing was that he'd resumed spontaneous ventilation on his own. Bottom line: he looked really difficult to mask, and I couldn't assume, based on what happened at the OSH, that it would be possible.

Did they say why the VL failed? Poor view or unable to position ETT? Did they attempt to ventilate between attempts? Why didn't they just put in an LMA for this Cystoscopy or was it a more complicated case?

If you are committed with the Awake FOI, I agree with others with needing more sedation. Your topicalization probably wasn't the problem

 

[Arch Guillotti]

ive just been doing midaz/remi, no lido at all and it goes fine.

uh, no thanks.

 

[DirtDocMD]

Get a nurse to grab the tongue with McGill’s, and pull the hell out of it. Try the McGills on the palm of your hand, sometime. They are “springy”, and you can’t squeeze them hard enough to make it hurt.

Avoid the ovassapian. Quick look with the bronchoscope. If you can see cords and they tolerate it, try and intubate. If you can see cords ok, and they don’t, you still know you’ve got a good enough view that you can give a good slug of propofol, and likely get it in.

Also, I try to stay out of the nose unless I’m DESPERATE. Not that it doesn’t work, but it doesn’t take much to get the bleeding started, and THEN you’ve got a real situation with visualizing anything...

 

[Aheadbyacentury]

Given previous airway management, one would think that the patient maintained easy ventilation during the multiple DL/VL attempts. Why not just go straight to asleep FOI instead of doing all this topicalization/sedation? My go to for the really difficult Intubation, while maintaining easy ventilation, is using both the VL and the FOB at the same time. Granted you need an extra set of hands and I only had to do this twice, but was amazed at how easy it was

This is a great idea if it works.... but a not so great (read TERRRIBLE) if it doesnt work..
Youre taking a guy who has a KNOWN difficult airway and putting them to sleep. The lawyers will have a field day.
Be conservative

 

[Aheadbyacentury]

65 yo M in pre-op for dental extraction planned for future implants. The usual comorbidities: morbid obesity, HTN, DM, OSA not using CPAP. His airway exam shows a thick neck, small mouth opening, big teeth, and a big tongue. Neck moves okay and he can sublet his mandible anterior to his maxillae teeth. Planned asleep glide until he says, "I was at the OSH having a cysto and they told me they had to wake me up to put the breathing tube in me. Whaddaya think that means, doc?"

I was able to pull up the records and, sure enough: multiple failed DL, failed VL, awoken (so assumed they could mask), and then did an "awake fiberoptic."

So my plan changed, but I do a fair number of sedated, topicalized fiberoptic intubations (I never call them awake; it freaks everyone out, and it's not even true).

I've written my routine here before, but, briefly:

Psychoprophylaxis
Glycopyrrolate
5% ointment to tongue in successive sweeps, each further back than the last.
Midazolam
to room

In the room, I keep them on the gurney, upright, monitors, NC oxygen.
4% lido spray to tonsils and over the top of the glottis
2% lido via transtracheal
Ovassapian Airway.

At this point, the patient is well-sedated and theoretically well-topicalized, but won’t tolerate the Ovassapian past the first couple inches.

I re-sprayed with more 4% and had him gargle. no change. 4% lido nebulizer. No change. More sedation, more 4% gargle, no change.

Oral surgeon humbly suggests maybe the nose. I reluctantly topicalized the L naris. couldn’t tolerate even the 30 nasopharyngeal airway despite aggressive topicalization.

So, is this lidocaine resistance? Certainly part of the tongue was numb, so probably not.

At this point, what’s your next move?

I love the description that you describe.. A lot of times folks just have a difficult gag for some reason..
Many times what you described works like a charm... it really does.. other times.. the above.. What I can think of is that the secretions nullified the effects of the lidocaine OR it wore off... STILL you did the hard work which is the trans tracheal you should have been able to power through the procedure. Alas. What you can do at last resort is stun him with propofol (40-50mg... not going to make him apneic) and take an awake look with the glidecope and if you see cords slide it in using the rigid stylet you have already numbed trachea.. if you are uncomfortable doing that you have the nares you can go through.. (dont use a nasal rae.use a reg tube. and put the tube in 1st til it reaches the back of the pharnyx then go with the fiberoptic.. and voila.. but your technique is spot-on.

Ive been meaning to ask the ent's about showing me how to do a superior laryngeal nerve blocks BILATwhich should quiet the gag.. but not sure if they are interested in showing me..

 

[Aheadbyacentury]

If you are committed with the Awake FOI, I agree with others with needing more sedation. Your topicalization probably wasn't the problem

I completely disagree, obviously the topicalization was the problem... And you have to be careful with sedation since you can sedate your way right into airway obstruction... and now you are doing a cric

 

[GassYous]

You need more local. Either transtracheal (16 g to neck) plus superior laryngeal (step off the hyoid bilaterally) or you can use lido lollipops behind there tonsillar pillars after drying out the mouth and then spraying the cords with the fiber.

 

[deleted697535]

uh, no thanks.

Sure.
Different strokes for different folks. But It is a reasonably well documented technique, safe and works well.
Im lazy so i like doing things the quickest way... Others love the 'performance' and 'art' of 'their' afoi technique that they invented.
I just like to sit down and buy stupid sh1t off amazon

 

[Blockit]

Be very careful with transtracheal injections. I remember doing them for years and then did one in a guy, and as the tube passed the cords and I pulled out the scope He took a huge breath and started coughing blood clots and blood out of the endotracheal tube. It was like a geyser. Then it stopped, and ventilation was fine, but I’m assuming that I got that small thyroidea ima arterial branch that exists in 5-10% of patients.

+1 On the remifentanil drip. Start at .1 mcg/kg/min and titrate up.

 

[Aheadbyacentury]

Be very careful with transtracheal injections. I remember doing them for years and then did one in a guy, and as the tube passed the cords and I pulled out the scope He took a huge breath and started coughing blood clots and blood out of the endotracheal tube. It was like a geyser. Then it stopped, and ventilation was fine, but I’m assuming that I got that small thyroidea ima arterial branch that exists in 5-10% of patients.

+1 On the remifentanil drip. Start at .1 mcg/kg/min and titrate up.

that is a lot of remi..

 

[deleted697535]

that is a lot of remi..

only if you never stop

by 6 mins of remi infusion around 0.1 pretty much everyone is 'ready'. then you stop or slowdown & intubate

doing the math on it, its generally about 50-90mcg for everyone, so i dont even bother with the infusion anymore and bolus 10-15mcg each minute for 6 minutes

works just fine
The key to it is observing the patient. they will tell you they are ready when a light shoulder push elicits a sluggish response or similiar type of RAS score

 

[fakin' the funk]

Asleep AirQ LMA, FOB

 

[Airway]

If you have it and you think an lma will ventilate oxygenate (and lma isn't contraindicated) fine the arndt exchange catheter is a nice device. Allows you to bypass topicalization, induce ga, lma, while continuing ventilation bronch, wire, remove bronchoscope, place exchange catheter over wire remove lma, place ett. Easy. No financial disclosure.

Products - Cook Medical

The Arndt Airway Exchange Catheter Set is intended for exchange of a supraglottic airway device (SAD) to an endotracheal tube (ETT) under bronchoscopic assistance, and for ETT exchange in adult and pediatric patients. The product may be used for emergency, urgent, and elective airway...

www.cookmedical.com

 

[Wolverines83]

think about precedex? 1mcg/kg loading dose on top of what you did there would have helped quite a bit and wouldn't burn any bridges.

I think some patients just feel something, anything and they're like "Oh my God I feel it!!!" Then they lose their mind and it just sucks.

So psychoprophylaxis (nice word), topicalize, precedex, topicalize, add ketamine if that's not enough (you already gave glyco).

 

[GassYous]

Yeah you have to tell the patient what is gonna happen in detail before you do it. 2 of midaz, 75 of fent and remi at 0.1 is how I was taught. I was taught by an attending who knows a ton about everything and it never failed. These days I skip the remi unless I really care about them coughing.

I've done precedex and it was successful but it definitely sucks compared to remi. You want something that suppresses the cough reflex and that's remi, not precedex.

 

[vector2]

I wanted to assume that MV would be possible. According to the OSH records (which, BTW, were from a real hospital with people I know and trust to be good), they gave succ, and part of the reason they "woke him up" after failing was that he'd resumed spontaneous ventilation on his own. Bottom line: he looked really difficult to mask, and I couldn't assume, based on what happened at the OSH, that it would be possible.

Makes me wonder how "good" they were if they attempted DL *multiple* times as you say in the OP......as opposed to a quick failed look at then going straight to VL or asleep fiber in a guy who sounds like a walking advertisement for a difficult airway.

This guy might not be a difficult VL in a situation where there weren't multiple failed DLs mucking up the tissue beforehand.

 

[Hoya11]

65 yo M in pre-op for dental extraction planned for future implants. The usual comorbidities: morbid obesity, HTN, DM, OSA not using CPAP. His airway exam shows a thick neck, small mouth opening, big teeth, and a big tongue. Neck moves okay and he can sublet his mandible anterior to his maxillae teeth. Planned asleep glide until he says, "I was at the OSH having a cysto and they told me they had to wake me up to put the breathing tube in me. Whaddaya think that means, doc?"

I was able to pull up the records and, sure enough: multiple failed DL, failed VL, awoken (so assumed they could mask), and then did an "awake fiberoptic."

So my plan changed, but I do a fair number of sedated, topicalized fiberoptic intubations (I never call them awake; it freaks everyone out, and it's not even true).

I've written my routine here before, but, briefly:

Psychoprophylaxis
Glycopyrrolate
5% ointment to tongue in successive sweeps, each further back than the last.
Midazolam
to room

In the room, I keep them on the gurney, upright, monitors, NC oxygen.
4% lido spray to tonsils and over the top of the glottis
2% lido via transtracheal
Ovassapian Airway.

At this point, the patient is well-sedated and theoretically well-topicalized, but won’t tolerate the Ovassapian past the first couple inches.

I re-sprayed with more 4% and had him gargle. no change. 4% lido nebulizer. No change. More sedation, more 4% gargle, no change.

Oral surgeon humbly suggests maybe the nose. I reluctantly topicalized the L naris. couldn’t tolerate even the 30 nasopharyngeal airway despite aggressive topicalization.

So, is this lidocaine resistance? Certainly part of the tongue was numb, so probably not.

At this point, what’s your next move?

i would deepen sedation, maintain spontaneous ventilation, and look to intubate with a Glidescope 4 while deeply sedated.

versed 4-6, fent 50-100, ketamine 50-100, propofol small bolus for backup if needed, lidocaine sprayed via atomizer - quick and portable (like for the ER)

once deeply sedated, glidescope gently in mouth, look at what we see - very often cords that are obvious due to the ongoing spontaneous breathing (even if shallow respirations from the sedation, once the glidescope blade is inserted, they start breathing very well), pass the tube as usual. tube goes in, they typically take a HUGE breath and cough and continue to breath spontaneously for while while I confirm ETCo2, tape, roc

 

[narcusprince]

In my 8-9 years of practice I have never needed to do a transtrachial localization for afoi. My technique is nebulized lidocaine 20 minutes prior to in room time. .2 glyco with 1 midazolam once leaving holding area. 1 mg midazolam.05 remifentanil. Williams airway in 3-4cc of 4% lidocaine through jet airway adapter. Remi to .1 1 min prior to scope insertion. Depending on mouth size and opening its through the Williams or glidescope assisted fiber. The Williams gives you a bit more anterior deflection versus the glidescope.

 

[GassYous]

Nebulized lido sucks. Just ask zippy

 

[Aether2000]

I have been successful with 4% nebulized lidocaine followed by use of a 25ga spinal needle to block CN IX by inserting the tip through the tonsillar pillar mucosa and injecting 2% lidocaine, 1 ml on each side.

 

[Katheudontas parateroumen]

For me, if I decide to do awake I don’t sedate at all if the patient is reasonable. Topical with 4% lido spray from ant and post tongue, tonsilar pillars and advancing back of pharynx and having them cough. Have a nasal cannula and go. If I need to sedate, I use things I can reverse with and short acting. Give time for things to work. Versed 0.5 at a time, remifentanil is my go to 10mcg at a time. For this case, sounds like you did all the topical you could spraying multiple times. It’s probably only sedation at this point. I would back out and retest with a cotton swab to see any spaces he would gag at and respray. If that doesn’t work, going for nasal I would use lots of vasoconstrictor spray (I’ve never used cocaine!) and spray lido and try dilating once.

Tough case though. What did you end up doing? Also, what do you all think of asleep FOBI? This patient still would look like a difficult MV. What’s your guys threshold to do asleep FOB? Would you try to avoid in someone with anyone with OSA or just bad OSA? I’ve only done asleep FOB on patients with c-spine injuries where they leave the collar in place but the patient is otherwise would appear easy intubation/MV.

 

[deleted162650]

Asleep AirQ LMA, FOB

Yup, those CookGas LMAs are the cat’s pajamas when it comes to intubating LMAs.

If you have it and you think an lma will ventilate oxygenate (and lma isn't contraindicated) fine the arndt exchange catheter is a nice device. Allows you to bypass topicalization, induce ga, lma, while continuing ventilation bronch, wire, remove bronchoscope, place exchange catheter over wire remove lma, place ett. Easy. No financial disclosure.

Products - Cook Medical

The Arndt Airway Exchange Catheter Set is intended for exchange of a supraglottic airway device (SAD) to an endotracheal tube (ETT) under bronchoscopic assistance, and for ETT exchange in adult and pediatric patients. The product may be used for emergency, urgent, and elective airway...

www.cookmedical.com

So there’s a better/cleaner way to do it. Induce and place LMA. Put a bronch elbow on the ETT, insert the ETT into the LMA about 1/2 way, and hook the circuit up to the bronch elbow. Now insert the FOB into the ETT via the bronch elbow, and you can ventilate continuously while driving the ETT into the trachea. No exchange catheter necessary. If it’s a short case, just leave the whole LMA/ETT complex in place throughout the case. If it’s a longer case, or you just want the LMA out, you can use one of those special ETT pushers to hold the ETT in place so it won’t back out with the LMA, or if you don’t have those, just use a second ETT that’s 1 size smaller as the plunger.

 

[Urzuz]

Yup, those CookGas LMAs are the cat’s pajamas when it comes to intubating LMAs.




So there’s a better/cleaner way to do it. Induce and place LMA. Put a bronch elbow on the ETT, insert the ETT into the LMA about 1/2 way, and hook the circuit up to the bronch elbow. Now insert the FOB into the ETT via the bronch elbow, and you can ventilate continuously while driving the ETT into the trachea. No exchange catheter necessary. If it’s a short case, just leave the whole LMA/ETT complex in place throughout the case. If it’s a longer case, or you just want the LMA out, you can use one of those special ETT pushers to hold the ETT in place so it won’t back out with the LMA, or if you don’t have those, just use a second ETT that’s 1 size smaller as the plunger.

Are you trying to teach the guy named @Airway intubation techniques?! The nerve...

 

[deleted697127]

65 yo M in pre-op for dental extraction planned for future implants. The usual comorbidities: morbid obesity, HTN, DM, OSA not using CPAP. His airway exam shows a thick neck, small mouth opening, big teeth, and a big tongue. Neck moves okay and he can sublet his mandible anterior to his maxillae teeth. Planned asleep glide until he says, "I was at the OSH having a cysto and they told me they had to wake me up to put the breathing tube in me. Whaddaya think that means, doc?"

I was able to pull up the records and, sure enough: multiple failed DL, failed VL, awoken (so assumed they could mask), and then did an "awake fiberoptic."

So my plan changed, but I do a fair number of sedated, topicalized fiberoptic intubations (I never call them awake; it freaks everyone out, and it's not even true).

I've written my routine here before, but, briefly:

Psychoprophylaxis
Glycopyrrolate
5% ointment to tongue in successive sweeps, each further back than the last.
Midazolam
to room

In the room, I keep them on the gurney, upright, monitors, NC oxygen.
4% lido spray to tonsils and over the top of the glottis
2% lido via transtracheal
Ovassapian Airway.

At this point, the patient is well-sedated and theoretically well-topicalized, but won’t tolerate the Ovassapian past the first couple inches.

I re-sprayed with more 4% and had him gargle. no change. 4% lido nebulizer. No change. More sedation, more 4% gargle, no change.

Oral surgeon humbly suggests maybe the nose. I reluctantly topicalized the L naris. couldn’t tolerate even the 30 nasopharyngeal airway despite aggressive topicalization.

So, is this lidocaine resistance? Certainly part of the tongue was numb, so probably not.

At this point, what’s your next move?

There needs to be a very good reason why I would put this guy to sleep for a dental extraction.

 

[propadope]

Anyone have a patient go apneic with remi for awake intubation? Morbidly obese pts can obviously be quite sensitive to narcotics. Even midazolam.

 

[propadope]

Also could you potentially do the case without tubing? Minimal or moderate sedation?

 

[cchoukal]

What a great discussion and I'm impressed by the diverse set of "next steps."

I posted this, in part, because I thought it was an interesting case and, in part, because although I've done a lot of these successfully, I was truly flummoxed by how difficult it was to topicalize this patient. I've never encountered this before.

To answer some of the questions:

Glyco dose was 0.2 well in advance of topicalization
I'm generally opposed to opiates in these cases; my thinking is that's what the local is for, and opiates + benzos + bad airway = apnea, but I respect that so many of you DO use opiates in this case and will consider it in the future.
By the point in the case I posted, we were 4 mg of midazolam in and, seemingly adequately sedated. We did give some ketamine (20 mg) at that point, at which point he began to open his eyes, shake his fists, and declare to the whole room, "I'M A JEDI!!!" over and over again.

 

[deleted875186]

What a great discussion and I'm impressed by the diverse set of "next steps."

I posted this, in part, because I thought it was an interesting case and, in part, because although I've done a lot of these successfully, I was truly flummoxed by how difficult it was to topicalize this patient. I've never encountered this before.

To answer some of the questions:

Glyco dose was 0.2 well in advance of topicalization
I'm generally opposed to opiates in these cases; my thinking is that's what the local is for, and opiates + benzos + bad airway = apnea, but I respect that so many of you DO use opiates in this case and will consider it in the future.
By the point in the case I posted, we were 4 mg of midazolam in and, seemingly adequately sedated. We did give some ketamine (20 mg) at that point, at which point he began to open his eyes, shake his fists, and declare to the whole room, "I'M A JEDI!!!" over and over again.

Wow …. Ketamine gone bad, I’m always afraid of this. Must be a big dude, 4mg versed and 20mg ketamine should really sedate most people.

 

[chessknt]

Wow …. Ketamine gone bad, I’m always afraid of this. Must be a big dude, 4mg versed and 20mg ketamine should really sedate most people.

Do you practice in America? I can’t say I’ve seen 4 of versed and 20 of ketamine sedate anyone between the rampant alcohol abuse and massive volume of distribution in my population.

 

[narcusprince]

Do you practice in America? I can’t say I’ve seen 4 of versed and 20 of ketamine sedate anyone between the rampant alcohol abuse and massive volume of distribution in my population.

Ketamine in my opinion is terrible for AFOI. Remimazolam + Remifentanil plus topicalization is a combo I would like to use.

 

[deleted545787]

65 yo M in pre-op for dental extraction planned for future implants. The usual comorbidities: morbid obesity, HTN, DM, OSA not using CPAP. His airway exam shows a thick neck, small mouth opening, big teeth, and a big tongue. Neck moves okay and he can sublet his mandible anterior to his maxillae teeth. Planned asleep glide until he says, "I was at the OSH having a cysto and they told me they had to wake me up to put the breathing tube in me. Whaddaya think that means, doc?"

I was able to pull up the records and, sure enough: multiple failed DL, failed VL, awoken (so assumed they could mask), and then did an "awake fiberoptic."

So my plan changed, but I do a fair number of sedated, topicalized fiberoptic intubations (I never call them awake; it freaks everyone out, and it's not even true).

I've written my routine here before, but, briefly:

Psychoprophylaxis
Glycopyrrolate
5% ointment to tongue in successive sweeps, each further back than the last.
Midazolam
to room

In the room, I keep them on the gurney, upright, monitors, NC oxygen.
4% lido spray to tonsils and over the top of the glottis
2% lido via transtracheal
Ovassapian Airway.

At this point, the patient is well-sedated and theoretically well-topicalized, but won’t tolerate the Ovassapian past the first couple inches.

I re-sprayed with more 4% and had him gargle. no change. 4% lido nebulizer. No change. More sedation, more 4% gargle, no change.

Oral surgeon humbly suggests maybe the nose. I reluctantly topicalized the L naris. couldn’t tolerate even the 30 nasopharyngeal airway despite aggressive topicalization.

So, is this lidocaine resistance? Certainly part of the tongue was numb, so probably not.

At this point, what’s your next move?

assuming you have all types of anesthetics at your disposal, My typical "awake" fiberoptic optic intubations goes as follows (briefly):

Preop: lidocaine 4% nebulizer (can do without it), preceded bolus 1mcg/kg over 10 minutes followed by an infusion, midazolam

roll back as soon as infusion is initiated

OR: preoxygenate, 0.3-0.5mg/kg of ketamine, insert scope. Once you see the cords, a touch of propofol (+/- sux)and go for the cords

emergence- protecting airway with responsive and purposeful movements

 

[GassYous]

Anyone have a patient go apneic with remi for awake intubation? Morbidly obese pts can obviously be quite sensitive to narcotics. Even midazolam.

No but at 0.1 they should be arousable and follow commands to breathe even if they aren't spontaneous.

Agree with narcus I think ketamine sucks here (dysphoria, secretions, sypathetic response/cardiac depression) and if you use it, it should be a decent dose like 1/kg imo. I haven't used it myself but I know the ed docs do a lot for their delayed sequence intubation.

Also could you potentially do the case without tubing? Minimal or moderate sedation?

Yes you can but if they bleed and aspirate or lose a tooth in the airway or whatnot you will wish you put the tube in earlier. I lost an airway once in a ludwig angina (awake fiber was successful into the airway but no end tidal after I passed tube), pt needed to be trached and I aged like 5 years.

 

[BLADEMDA]

Yeah you have to tell the patient what is gonna happen in detail before you do it. 2 of midaz, 75 of fent and remi at 0.1 is how I was taught. I was taught by an attending who knows a ton about everything and it never failed. These days I skip the remi unless I really care about them coughing.

I've done precedex and it was successful but it definitely sucks compared to remi. You want something that suppresses the cough reflex and that's remi, not precedex.

Precedex. Ketamine. Glycco. low dose midazolam. No opioids. FOB after topicalization. I would use a peds FOB to spray the cords really well. I have propofol and sux ready once I have a good view of the cords.

I too have performed the Glidescope/FOB intubation trick a few times and i think it works well. But, in this case I am NOT going to do that approach due to the REAL history of a difficult intubation and a difficult mask. I can tell you that in my practice I would have inserted an LMA in this patient (during the first surgery) and noted whether ventilation was easy or difficult. I also would have attempted an intubation through the LMA prior to waking him up the first time (assuming I could ventilate him through it).

Now, that's not to say I haven't encountered a very difficult to ventilate patient with an LMA and aborted the FOB through that device. In addition, I have even had to cancel a case due to nasal bleeding from attempting a nasal FOB. But, those are rare instances so I don't let them cloud my judgment or approach despite knowing they can occur and have happened to me.

 

[GassYous]

I've seen the glyco/fiberoptic trick fail one time in residency. It was done by 2 attendings and they tried for 10 minutes and ended up waking the patient up. Fat patient, large tongue, vascular guy bleeding on ac. Did the case with sedation and local and patient amazingly ended up doing okay.

I have also had several patients be unventilatable with LMAs. Tall black males (>6 feet, >100 kg) in the outpatient center that ended up needing tubes. N = 4 or so.

 

[BLADEMDA]

Wow …. Ketamine gone bad, I’m always afraid of this. Must be a big dude, 4mg versed and 20mg ketamine should really sedate most people.

Ketamine in these types of situations should be low dose and used with other medications. Too many "providers" give too much ketamine IMHO.

 

[GassYous]

Ketamine in these types of situations should be low dose and used with other medications. Too many "providers" give too much ketamine IMHO.

I don't give more than 30 except in spine where I max out at 200. But there was a recent study in anesthesiology that basically said ketamine/mg vs control is no different in pain in the long term. I use it mostly for boosting signal but wonder if it's worth using.

 

[BLADEMDA]

Honestly, the younger guys rely too much on Plan A and Plan B and that has shifted our practice away from true difficult airway management. I like the VL devices. They are revolutionary like the LMA was in the 1990s. But, the LMA and the VL will fail 1-2% of the time so we all must have a plan "C" on our list.

I'd rather wake the patient up alive and try again in 1-2 weeks then deal with the consequences of a failed airway. The only thing that really gets hurt if your can't intubate the big fat guy SAFELY is your pride.

 

[BLADEMDA]

I used this all the time for oral fiberoptic intubations prior to the LMA and the VL. Do they still use this device in residency training today (past 5 years)?

 

[BLADEMDA]

What a great discussion and I'm impressed by the diverse set of "next steps."

I posted this, in part, because I thought it was an interesting case and, in part, because although I've done a lot of these successfully, I was truly flummoxed by how difficult it was to topicalize this patient. I've never encountered this before.

To answer some of the questions:

Glyco dose was 0.2 well in advance of topicalization
I'm generally opposed to opiates in these cases; my thinking is that's what the local is for, and opiates + benzos + bad airway = apnea, but I respect that so many of you DO use opiates in this case and will consider it in the future.
By the point in the case I posted, we were 4 mg of midazolam in and, seemingly adequately sedated. We did give some ketamine (20 mg) at that point, at which point he began to open his eyes, shake his fists, and declare to the whole room, "I'M A JEDI!!!" over and over again.

I have been in a few cases where the LMA failed to ventilate the patient adequately. Typically, a morbidly obese patient where despite 2-3 LMAs (different sizes and techniques) the ventilation was inadequate. What I did was perform a jaw lift maneuver with both hands ( a lot of force) while an assistant pushed down on the LMA. The midlevel provider would then attempt some manual assisted ventilation with the breathing bag (100% O2) This would buy me enough time to intubate the patient with a VL while maintaining saturations above 90 percent. My point being that even a "failed LMA" can buy you a few extra minutes to either intubate with a VL or wake the patient up.

Of course, others may try the same technique but substitute an oral airway for the failed LMA combined a strong, powerful jaw thrust.

I would like to state that the most difficult airways I have ever encountered in my career were either quite obvious or were patients with severe laryngeal malignancies (some were treated with radiation while others were not). These patients typically appear thin and easy to the untrained eye but they can be a disaster in the making far worse than this case being discussed here.

 

[Arch Guillotti]

I lost an airway once in a ludwig angina (awake fiber was successful into the airway but no end tidal after I passed tube), pt needed to be trached and I aged like 5 years.

So you didn’t pass the tube in the airway. Did the patient suddenly decompensate or did you push induction drugs before etco2 was confirmed?

 

[propadope]

No but at 0.1 they should be arousable and follow commands to breathe even if they aren't spontaneous.

Agree with narcus I think ketamine sucks here (dysphoria, secretions, sypathetic response/cardiac depression) and if you use it, it should be a decent dose like 1/kg imo. I haven't used it myself but I know the ed docs do a lot for their delayed sequence intubation.



Yes you can but if they bleed and aspirate or lose a tooth in the airway or whatnot you will wish you put the tube in earlier. I lost an airway once in a ludwig angina (awake fiber was successful into the airway but no end tidal after I passed tube), pt needed to be trached and I aged like 5 years.

Should be arousable at 0.1 but this population has a very unpredictable response to narcs. Precedex is a great adjunct to go along with the ketamine to blunt the sympathetic response, and decrease secretions along with glyco. Yes ketamine or precedex on its own is not a great drug.

I almost always prefer a tube but nothing is without risk in this patient either way. How many teeth are being extracted? Also how much intraoral local is needed? Is there a risk of LAST with more topicalization needed to tube? The amount of sedation needed to do an AFOI could exceed what is needed to get the procedure done.

Disclaimer: I’m a dentist and do office based anaesthesia so I am just conjecturing. I don’t do AFOI but I have in my training, which was many years ago.

 

[narcusprince]

View attachment 338418

I used this all the time for oral fiberoptic intubations prior to the LMA and the VL. Do they still use this device in residency training today (past 5 years)?

The Williams airway. Anterior deflection gets tongue out of the way…. Now if someone attached a camera to it…….