"Awake Fiberoptic" Intubation

[deleted875186]

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

We used this in residency… didn’t know what the name of it was.

looked up the history, looks like this airway was designed before bronchoscopy was widespread, it was initially designed for blind oral intubation, and apparently had an 85% success rate.

---

Members don't see this ad.

 

[GassYous]

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?

Second. Tube felt like it passed easily and I thought I was looking at tube as the bronch came out but obviously not

 

[ethilo]

In residency, I did quite a few awake FOBs in a few different ways and I thought I found the best way (it IS very good), however in PP I've changed things around because it just takes too long and too much mental effort, so here's what I've done now that seems to work good enough:

0.2 mg glyco in holding area
maybe a touch of versed based on the patient
Lots of psychoppx

Then in the room I use 2 LTAS since they are in the cart. First is to gargle for 1 minute by the clock. Then I stand facing the patient and tomahawk a glidescope blade. I advance the blade slowly and carefully, if any reaction then I back off and have them gargle more lido. Eventually you will get a good look at the cords. I then LTA the cords by VL. Gauging reactivity the whole time and topicalizing as I go. Eventually I get the styletted tube in the mouth above the cords, then tell them to take a deep breath, and intubate quickly, then prop them fast for lights out.

 

[coffeebythelake]

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.

What difference would 16g for transtracheal vs 20g? It's the dose of local you apply that matters not the size of thr hole in the cricothyroid membrane

 

[coffeebythelake]

Second. Tube felt like it passed easily and I thought I was looking at tube as the bronch came out but obviously not

Coughed it out? Or never in?

 

[GassYous]

What difference would 16g for transtracheal vs 20g? It's the dose of local you apply that matters not the size of thr hole in the cricothyroid membrane

Easier to jet if needed

Coughed it out? Or never in?

I think it was never in, probably kinked up at the cords and I pulled it totally out when I removed the fiberoptic.

 

[coffeebythelake]

Easier to jet if needed

I typically use a 20g angiocath and pull it out immediately after applying the lidocaine. Do you leave your 16g cath in?

 

[GassYous]

I typically use a 20g angiocath and pull it out immediately after applying the lidocaine. Do you leave your 16g cath in?

Nah but that was the idea of it

 

[deleted162650]

It's the dose of local you apply that matters not the size of thr hole

Giggidy.

 

[Gern Blansten]

I like the following method:
Glycopyrrolate 0.2 mg IV in holding area
Atomized 4% lidocaine sprayed in nose and posterior oropharynx 5 minutes prior to beginning

Lidocaine ointment on a tongue depressor inserted on back of tongue and advanced incrementally
30 Fr Nasal airway saturated externally with lido ointment with a 7.0 ETT adapter inserted into the proximal portion of the nasal airway

Hook up the anesthesia circuit to the ETT adapter and dial in Sevo 1-2% and 8-10 liters of O2
The patient will spontaneously ventilate and control their own depth of anesthesia while also delivering 98% O2 directly into the posterior oropharynx which will greatly decrease the chance of desaturation mid procedure
Remove the tongue blade and insert an Ovassapian airway (or other of your choice or pull the tongue forward)
Insert FOB and proceed with FOI in a patient that will exhibit very little discomfort or recall of events
This has worked well for me about 95% of the time
Occasionally, add a video laryngoscope assisted FOI if the topicalization allows insertion of the Storz or glidescope
Drive the FOB all the way to the carina, Optional: push a 1/4 of the dose of propofol to facilitate advancement of the tube without it going into the esophagus and popping the scope out of the trachea. Reconfirm tracheal placement on the screen after advancing the tube into place. Confirm ETCO2 and give the remaining dose of propofol needed (probably a reduced total dose due to the presence of the sevoflurane)
Obviously not a good option in an ICU setting because vaporizers not available

 

[surgndoc]

I like the following method:
Glycopyrrolate 0.2 mg IV in holding area
Atomized 4% lidocaine sprayed in nose and posterior oropharynx 5 minutes prior to beginning
View attachment 338596
Lidocaine ointment on a tongue depressor inserted on back of tongue and advanced incrementally
30 Fr Nasal airway saturated externally with lido ointment with a 7.0 ETT adapter inserted into the proximal portion of the nasal airway
View attachment 338597
Hook up the anesthesia circuit to the ETT adapter and dial in Sevo 1-2% and 8-10 liters of O2
The patient will spontaneously ventilate and control their own depth of anesthesia while also delivering 98% O2 directly into the posterior oropharynx which will greatly decrease the chance of desaturation mid procedure
Remove the tongue blade and insert an Ovassapian airway (or other of your choice or pull the tongue forward)
Insert FOB and proceed with FOI in a patient that will exhibit very little discomfort or recall of events
This has worked well for me about 95% of the time
Occasionally, add a video laryngoscope assisted FOI if the topicalization allows insertion of the Storz or glidescope
Drive the FOB all the way to the carina, Optional: push a 1/4 of the dose of propofol to facilitate advancement of the tube without it going into the esophagus and popping the scope out of the trachea. Reconfirm tracheal placement on the screen after advancing the tube into place. Confirm ETCO2 and give the remaining dose of propofol needed (probably a reduced total dose due to the presence of the sevoflurane)
Obviously not a good option in an ICU setting because vaporizers not available

This is good I may try this next time. Basically same as what I already do for topicalization, but I like the touch of the nasal airway and sevo if going the oral route.

as other may have said, nasal is commonly a better approach as it lines the scope up with the glottis better from the nasopharynx as compared to the mouth. Especially in patients with tumors, radiation, etc it can be difficult to make extreme anterior angulation with a scope from the mouth. Looking at a ct can be helpful to make your decision.

 

[VisionaryTics]

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

I'm a head and neck surgery fellow, but I've had two patients nearly lose airway in last month because of remifentinil oversedation during awake airways.

One was a guy with bilateral cord paralysis/frozen larynx from chemoradiation 15 years prior. His neck was stone. He had slowly progressive symptoms over weeks and was comfortable laying flat, not in extremis. As I was getting down to airway (couldn't feel any landmarks, neck was just concrete scar), patient became apneic from sedation and brady'd down to 20 as I got airway in.

Second was a guy with a tonsil cancer, but patent airway, who presented to hospital with a massive stroke. He had no airway issues, but had worsening mental status, so anesthesia took to OR for an awake fiberoptic with ENT on backup. He started snoring violently from the sedation, and the tumor started bleeding profusely from the snoring, without any instrumentation. Had to convert to an urgent awake trach.

Both cases I have a lot of regret about the multidisciplinary airway management. Both cases involved anesthesiologists not interested in our input on the situation until it became dire. This is two cases in the last month, but I've seen many more in my short career where oversedation turned the airway urgency into an emergency. I have done fiberoptic examinations of the larynx in literally thousands of patients in the clinic without sedation, and I can only think of a single mentally competent adult that did not tolerate scope enough to the point I couldn't examine larynx.

 

[2Fast2Des]

I'm a head and neck surgery fellow, but I've had two patients nearly lose airway in last month because of remifentinil oversedation during awake airways.

One was a guy with bilateral cord paralysis/frozen larynx from chemoradiation 15 years prior. His neck was stone. He had slowly progressive symptoms over weeks and was comfortable laying flat, not in extremis. As I was getting down to airway (couldn't feel any landmarks, neck was just concrete scar), patient became apneic from sedation and brady'd down to 20 as I got airway in.

Second was a guy with a tonsil cancer, but patent airway, who presented to hospital with a massive stroke. He had no airway issues, but had worsening mental status, so anesthesia took to OR for an awake fiberoptic with ENT on backup. He started snoring violently from the sedation, and the tumor started bleeding profusely from the snoring, without any instrumentation. Had to convert to an urgent awake trach.

Both cases I have a lot of regret about the multidisciplinary airway management. Both cases involved anesthesiologists not interested in our input on the situation until it became dire. This is two cases in the last month, but I've seen many more in my short career where oversedation turned the airway urgency into an emergency. I have done fiberoptic examinations of the larynx in literally thousands of patients in the clinic without sedation, and I can only think of a single mentally competent adult that did not tolerate scope enough to the point I couldn't examine larynx.

Well not sure what your anesthesiologist colleagues did, but there is an art to this as you know and **** can happen no matter in whatever scenario. When it comes to the OR, patients freak out and want zero recall of even the wall paint color. Trying to balance amnesia with out losing an airway on an anxious patient while trying to ram in a PVC into their airways can be a challenge. Maybe they were heavy handed, maybe pt was in extremis, but I'd need to know a bit more as to what the heck happened that needed conversion to trach. What were your suggestions that you think may have averted those scenarios you described?

 

[GassYous]

I'm a head and neck surgery fellow, but I've had two patients nearly lose airway in last month because of remifentinil oversedation during awake airways.

One was a guy with bilateral cord paralysis/frozen larynx from chemoradiation 15 years prior. His neck was stone. He had slowly progressive symptoms over weeks and was comfortable laying flat, not in extremis. As I was getting down to airway (couldn't feel any landmarks, neck was just concrete scar), patient became apneic from sedation and brady'd down to 20 as I got airway in.

Second was a guy with a tonsil cancer, but patent airway, who presented to hospital with a massive stroke. He had no airway issues, but had worsening mental status, so anesthesia took to OR for an awake fiberoptic with ENT on backup. He started snoring violently from the sedation, and the tumor started bleeding profusely from the snoring, without any instrumentation. Had to convert to an urgent awake trach.

Both cases I have a lot of regret about the multidisciplinary airway management. Both cases involved anesthesiologists not interested in our input on the situation until it became dire. This is two cases in the last month, but I've seen many more in my short career where oversedation turned the airway urgency into an emergency. I have done fiberoptic examinations of the larynx in literally thousands of patients in the clinic without sedation, and I can only think of a single mentally competent adult that did not tolerate scope enough to the point I couldn't examine larynx.

Thanks for sharing your valuable contribution. You saved those patients' lives. But at the very least, the anesthesiologists recognized that this worst case scenario can happen and you were ready. Sedation is a difficult art. It's easy to just throw a tube in but getting the patient to exactly where you want is not easy. I don't worry in most general cases. It's the "mac" cases that scare me the most.

Isn't your fiberoptic a lot smaller and flexible than ours? Ours has to accomodate an ett over it.

 

[VisionaryTics]

Well not sure what your anesthesiologist colleagues did, but there is an art to this as you know and **** can happen no matter in whatever scenario. When it comes to the OR, patients freak out and want zero recall of even the wall paint color. Trying to balance amnesia with out losing an airway on an anxious patient while trying to ram in a PVC into their airways can be a challenge. Maybe they were heavy handed, maybe pt was in extremis, but I'd need to know a bit more as to what the heck happened that needed conversion to trach. What were your suggestions that you think may have averted those scenarios you described?

The conversation is usually "This guy has a very tenuous airway, I wouldn't sedate him at all" followed by either "I'll use remi, it'll be easy to titrate off" or "Don't worry about the anesthetic, I'll take care of it". It's frustrating as a physician to have your concerns dismissed, when usually I'm the only guy who's actually seen the patient's larynx, and then to see the disaster unfold in front of you.

Thanks for sharing your valuable contribution. You saved those patients' lives. But at the very least, the anesthesiologists recognized that this worst case scenario can happen and you were ready. Sedation is a difficult art. It's easy to just throw a tube in but getting the patient to exactly where you want is not easy. I don't worry in most general cases. It's the "mac" cases that scare me the most.

Isn't your fiberoptic a lot smaller and flexible than ours? Ours has to accomodate an ett over it.

Our flex laryngoscopes are usually about 2/3 the size of a diagnostic bronch, about the size of a pediatric bronch. Our working channel laryngoscopes for in office biopsies/dilations/etc are the same size as a bronch, and patients tolerate prolonged instrumentation (15-30 minutes sometimes) of their airway pretty well with proper positioning, topical anesthesia, and "talkesthesia".

I didn't share my experiences to cast aspersions. I love reading this forum and getting anesthesiologist's perspective on difficult airway problems. I think multidisciplinary airway care is one of the best parts of my job. I suppose in my experience, good technique, topicalization, positioning, and talking to the patient will get you 99% of the way there towards a safe airway.

 

[deleted697535]

I'm a head and neck surgery fellow, but I've had two patients nearly lose airway in last month because of remifentinil oversedation during awake airways.

One was a guy with bilateral cord paralysis/frozen larynx from chemoradiation 15 years prior. His neck was stone. He had slowly progressive symptoms over weeks and was comfortable laying flat, not in extremis. As I was getting down to airway (couldn't feel any landmarks, neck was just concrete scar), patient became apneic from sedation and brady'd down to 20 as I got airway in.

Second was a guy with a tonsil cancer, but patent airway, who presented to hospital with a massive stroke. He had no airway issues, but had worsening mental status, so anesthesia took to OR for an awake fiberoptic with ENT on backup. He started snoring violently from the sedation, and the tumor started bleeding profusely from the snoring, without any instrumentation. Had to convert to an urgent awake trach.

Both cases I have a lot of regret about the multidisciplinary airway management. Both cases involved anesthesiologists not interested in our input on the situation until it became dire. This is two cases in the last month, but I've seen many more in my short career where oversedation turned the airway urgency into an emergency. I have done fiberoptic examinations of the larynx in literally thousands of patients in the clinic without sedation, and I can only think of a single mentally competent adult that did not tolerate scope enough to the point I couldn't examine larynx.

Thank you

Just trying to decrypt your cases and your overall point.

What is your point? Is it about remi? Or inattentive anesthesia?

1st case seems strange. why do 'awake trache' for cord paralysis? The cords should be wide open!! And why give remi for awake trache. Thats why its called awake trache? Where i learned it, is if you are going that far, they get some hand holding from a nurse and an apology. No sedation

2nd case the patient mass bled violently from the force of a snore? Tbh sounds like a no win situation either way...

With all these cases, the retro-spectoscope is the the best (and worst) option. Who is to say if a different means was chosen a worse outcome wouldnt have occured? These cases are art not science, each one is N=1 .

Remi is a dangerous weapon in the hands of a fool, or an unlucky person

Guns dont kill people, people kill people

 

[deleted162650]

If opioids are a part of your AFOI recipe, you should have a stick of narcan drawn and ready. Yes, even if that opioid is remi - it ain’t as fast off as you think it is.

 

[Arch Guillotti]

1st case seems strange. why do 'awake trache' for cord paralysis? The cords should be wide open!! And why give remi for awake trache. Thats why its called awake trache? Where i learned it, is if you are going that far, they get some hand holding from a nurse and an apology. No sedation

My take is that an "awake" intubation was attempted but went awry.

 

[Arch Guillotti]

I like the following method:
Glycopyrrolate 0.2 mg IV in holding area
Atomized 4% lidocaine sprayed in nose and posterior oropharynx 5 minutes prior to beginning
View attachment 338596
Lidocaine ointment on a tongue depressor inserted on back of tongue and advanced incrementally
30 Fr Nasal airway saturated externally with lido ointment with a 7.0 ETT adapter inserted into the proximal portion of the nasal airway
View attachment 338597
Hook up the anesthesia circuit to the ETT adapter and dial in Sevo 1-2% and 8-10 liters of O2
The patient will spontaneously ventilate and control their own depth of anesthesia while also delivering 98% O2 directly into the posterior oropharynx which will greatly decrease the chance of desaturation mid procedure
Remove the tongue blade and insert an Ovassapian airway (or other of your choice or pull the tongue forward)
Insert FOB and proceed with FOI in a patient that will exhibit very little discomfort or recall of events
This has worked well for me about 95% of the time
Occasionally, add a video laryngoscope assisted FOI if the topicalization allows insertion of the Storz or glidescope
Drive the FOB all the way to the carina, Optional: push a 1/4 of the dose of propofol to facilitate advancement of the tube without it going into the esophagus and popping the scope out of the trachea. Reconfirm tracheal placement on the screen after advancing the tube into place. Confirm ETCO2 and give the remaining dose of propofol needed (probably a reduced total dose due to the presence of the sevoflurane)
Obviously not a good option in an ICU setting because vaporizers not available

Which atomizer do you use for the nose? The one pictured or the short stubby one for pediatric versed?

 

[Arch Guillotti]

I like the following method:
Glycopyrrolate 0.2 mg IV in holding area
Atomized 4% lidocaine sprayed in nose and posterior oropharynx 5 minutes prior to beginning
View attachment 338596
Lidocaine ointment on a tongue depressor inserted on back of tongue and advanced incrementally
30 Fr Nasal airway saturated externally with lido ointment with a 7.0 ETT adapter inserted into the proximal portion of the nasal airway
View attachment 338597
Hook up the anesthesia circuit to the ETT adapter and dial in Sevo 1-2% and 8-10 liters of O2
The patient will spontaneously ventilate and control their own depth of anesthesia while also delivering 98% O2 directly into the posterior oropharynx which will greatly decrease the chance of desaturation mid procedure
Remove the tongue blade and insert an Ovassapian airway (or other of your choice or pull the tongue forward)
Insert FOB and proceed with FOI in a patient that will exhibit very little discomfort or recall of events
This has worked well for me about 95% of the time
Occasionally, add a video laryngoscope assisted FOI if the topicalization allows insertion of the Storz or glidescope
Drive the FOB all the way to the carina, Optional: push a 1/4 of the dose of propofol to facilitate advancement of the tube without it going into the esophagus and popping the scope out of the trachea. Reconfirm tracheal placement on the screen after advancing the tube into place. Confirm ETCO2 and give the remaining dose of propofol needed (probably a reduced total dose due to the presence of the sevoflurane)
Obviously not a good option in an ICU setting because vaporizers not available

This is brilliant except I would be hesitant to do it in someone morbidly obese or very limited mouth opening. Also you could do the fiber nasally using the nasal airway as a conduit.

 

[VisionaryTics]

My take is that an "awake" intubation was attempted but went awry.

It wasn't cord paralysis related to nerve paralysis, more of a frozen larynx from chemoradiation. Cords weren't moving because of posterior glottic stenosis, glottic aperture about 3mm. The tissue was like concrete, wouldn't have even been able to get a rigid bronch through the cords. So plan was awake trach from the start.

 

[Arch Guillotti]

It wasn't cord paralysis related to nerve paralysis, more of a frozen larynx from chemoradiation. Cords weren't moving because of posterior glottic stenosis, glottic aperture about 3mm. The tissue was like concrete, wouldn't have even been able to get a rigid bronch through the cords. So plan was awake trach from the start.

Got it. I have never used remi for an awake intubation and never will just because these airways are fortunately pretty rare and I would rather use something I am familiar with. No chance on earth I would ever use it for an awake trach.

 

[Arch Guillotti]

I have done fiberoptic examinations of the larynx in literally thousands of patients in the clinic without sedation, and I can only think of a single mentally competent adult that did not tolerate scope enough to the point I couldn't examine larynx.

A lot of us don't do it that often or give it time to work.

 

[deleted697535]

The scope ive seen ent use in their clinic bears little resemblance to an intubating bronchoscope with an adult sized ET loaded. I dont remember the caliber but the one i saw them using most often was as fine as even our smallest peds scope. totally useless as a conduit for adult intubation but much more easily tolerated

 

[propadope]

If the patient is a bad gagger, your oral surgeon colleague could do bilateral lingual (+inferior alveolar) and greater palatine nerve blocks. He may or may not need this anyways for the procedure but it would (should) numb his tongue and soft palate

 

[Gern Blansten]

Which atomizer do you use for the nose? The one pictured or the short stubby one for pediatric versed?

The same one pictured. I believe the brand is called MADgic® Laryngo-Tracheal Mucosal Atomization Device

 

[GassYous]

If the patient is a bad gagger, your oral surgeon colleague could do bilateral lingual (+inferior alveolar) and greater palatine nerve blocks. He may or may not need this anyways for the procedure but it would (should) numb his tongue and soft palate

I will try this on my gf

 

[propadope]

I will try this on my gf

Might want to add the glossopharyngeal then

 

[cchoukal]

Might want to add the glossopharyngeal then

I wonder if this is why the GF of the guy in the other post got a restraining order.

 

[nimbus]

I wonder if this is why the GF of the guy in the other post got a restraining order.

Because he did or didn’t add the glossopharyngeal nerve block?

 

[Ezekiel2517]

Which atomizer do you use for the nose? The one pictured or the short stubby one for pediatric versed?

For the nose, one thing I like to do is spray them with phenylephrine nasal spray (to prevent bleeding), then take the cap off the bottle, dump the phenylephrine solution, fill it with 4% lidocaine, and have them spray their nostrils. I actually like the nasal approach more than most ppl. Why? It's quicker bc it's a straight shot and the cords are staring at you once you get the scope thru the nasal passage, especially if you use the ETT as a railroad for the scope (ie: as if you were doing a nasal intubation)

 

[deleted697127]

Well not sure what your anesthesiologist colleagues did, but there is an art to this as you know and **** can happen no matter in whatever scenario. When it comes to the OR, patients freak out and want zero recall of even the wall paint color. Trying to balance amnesia with out losing an airway on an anxious patient while trying to ram in a PVC into their airways can be a challenge. Maybe they were heavy handed, maybe pt was in extremis, but I'd need to know a bit more as to what the heck happened that needed conversion to trach. What were your suggestions that you think may have averted those scenarios you described?

Not directed at you just my thoughts in general. Patients want to not die. Set expectations and calmly discuss your thought process and most patients will understand. Sometimes we project and assume what patients want. Sure some adamantly demand absolutely no recall under all circumstances but you can’t always get what you want. I have done awake looks with VL with minimal sedation on BMI 60 malampati 3/4 and have found it helpful. It doesn’t guarantee the view will be the same after induction, but i have found the view after induction has been somewhat similar. Particularly helps me optimize angles, depth, etc. Point being, the patients were completely fine with the approach. “I’m overweight. I burn through oxygen fast making placing an airway dangerous. Sure, i trust you if you think that’s what’s best.” Not all patients are unreasonable.

I'm a head and neck surgery fellow, but I've had two patients nearly lose airway in last month because of remifentinil oversedation during awake airways.

One was a guy with bilateral cord paralysis/frozen larynx from chemoradiation 15 years prior. His neck was stone. He had slowly progressive symptoms over weeks and was comfortable laying flat, not in extremis. As I was getting down to airway (couldn't feel any landmarks, neck was just concrete scar), patient became apneic from sedation and brady'd down to 20 as I got airway in.

Second was a guy with a tonsil cancer, but patent airway, who presented to hospital with a massive stroke. He had no airway issues, but had worsening mental status, so anesthesia took to OR for an awake fiberoptic with ENT on backup. He started snoring violently from the sedation, and the tumor started bleeding profusely from the snoring, without any instrumentation. Had to convert to an urgent awake trach.

Both cases I have a lot of regret about the multidisciplinary airway management. Both cases involved anesthesiologists not interested in our input on the situation until it became dire. This is two cases in the last month, but I've seen many more in my short career where oversedation turned the airway urgency into an emergency. I have done fiberoptic examinations of the larynx in literally thousands of patients in the clinic without sedation, and I can only think of a single mentally competent adult that did not tolerate scope enough to the point I couldn't examine larynx.

What caused the Brady? Remi or hypoxia? Did you guys debrief after? Sounds like communication could be improved between your departments. Seems like these would be good cases for interdepartmental M and M. I miss some of that stuff from residency.

 

[propadope]

Not directed at you just my thoughts in general. Patients want to not die. Set expectations and calmly discuss your thought process and most patients will understand. Sometimes we project and assume what patients want. Sure some adamantly demand absolutely no recall under all circumstances but you can’t always get what you want. I have done awake looks with VL with minimal sedation on BMI 60 malampati 3/4 and have found it helpful. It doesn’t guarantee the view will be the same after induction, but i have found the view after induction has been somewhat similar. Particularly helps me optimize angles, depth, etc. Point being, the patients were completely fine with the approach. “I’m overweight. I burn through oxygen fast making placing an airway dangerous. Sure, i trust you if you think that’s what’s best.” Not all patients are unreasonable.




What caused the Brady? Remi or hypoxia? Did you guys debrief after? Sounds like communication could be improved between your departments. Seems like these would be good cases for interdepartmental M and M. I miss some of that stuff from residency.

I think the remi caused the brady

 

[nimbus]

This thread reminds of one of my awake nasal FOB intubations from residency. My attending thought it would be a good idea to give a little iv fentanyl and topicalize with 4% cocaine. His last words before he was intubated were, “God bless you son! God bless you!!”

 

[Hoya11]

I'm a head and neck surgery fellow, but I've had two patients nearly lose airway in last month because of remifentinil oversedation during awake airways.

One was a guy with bilateral cord paralysis/frozen larynx from chemoradiation 15 years prior. His neck was stone. He had slowly progressive symptoms over weeks and was comfortable laying flat, not in extremis. As I was getting down to airway (couldn't feel any landmarks, neck was just concrete scar), patient became apneic from sedation and brady'd down to 20 as I got airway in.

Second was a guy with a tonsil cancer, but patent airway, who presented to hospital with a massive stroke. He had no airway issues, but had worsening mental status, so anesthesia took to OR for an awake fiberoptic with ENT on backup. He started snoring violently from the sedation, and the tumor started bleeding profusely from the snoring, without any instrumentation. Had to convert to an urgent awake trach.

Both cases I have a lot of regret about the multidisciplinary airway management. Both cases involved anesthesiologists not interested in our input on the situation until it became dire. This is two cases in the last month, but I've seen many more in my short career where oversedation turned the airway urgency into an emergency. I have done fiberoptic examinations of the larynx in literally thousands of patients in the clinic without sedation, and I can only think of a single mentally competent adult that did not tolerate scope enough to the point I couldn't examine larynx.

examining the larynx with a small scope through the nose in the office is a different animal compared to emergently intubating a distressed patient with an acutely decompensating airway. I hear this a lot from ENT like it would be no problem for them, but few have actually passed the tube on an awake patient.. no matter what you do - a good number of them cough and buck ...

i usually hate ketamine but for these situations its the best IV agent IMO to keep spontaneous ventilation while also rendering the patient unconscious..
i think a small dose of fentanyl like 50-100 is usually tolerated by most anyone, and can reduce airway reactivity, increase tube acceptance, and not interfere with respirations..

 

[nimbus]

examining the larynx with a small scope through the nose in the office is a different animal compared to emergently intubating a distressed patient with an acutely decompensating airway. I hear this a lot from ENT like it would be no problem for them, but few have actually passed the tube on an awake patient.. no matter what you do - a good number of them cough and buck ...

i usually hate ketamine but for these situations its the best IV agent IMO to keep spontaneous ventilation while also rendering the patient unconscious..
i think a small dose of fentanyl like 50-100 is usually tolerated by most anyone, and can reduce airway reactivity, increase tube acceptance, and not interfere with respirations..

Would be nice to hear from a pulmonologist who does a lot of bronchoscopy. The ones I’ve witnessed have all required sedation, slow methodical topicalization, more topicalization through the scope, and a lot of handholding. Still the patients are usually tearing up.

 

[vector2]

Would be nice to hear from a pulmonologist who does a lot of bronchoscopy. The ones I’ve witnessed have all required sedation, slow methodical topicalization, more topicalization through the scope, and a lot of handholding. Still the patients are usually tearing up.

A couple years back we started insisting on putting pulm cases (even BALs) to sleep. Their topicalization was never, ever good enough, and the pt was always desatting due to unending bucking and coughing. Many of these I could've probably managed to mac on my own but leaving a CRNA in there in a case like that without a protected airway was untenable.

 

[deleted697535]

Did a list of subglottic stenosis dilatations on wednesday. That was fun!
Remi prop tiva, intermittent vent thru the rigid bronch. actually went great

 

[BLADEMDA]

This thread is more evidence that the worst airways are typically malignancy related to the larynx/throat or post radiation to the larynx/throat. My point being I have seen too many cavalier attitudes from junior attendings about what can go wrong with these patients. You must be prepared with these patients every single time for plans A, B and C with the understanding that LMAs have a much higher failure rate in this subgroup. For those still in residency or just a few years out I can personally attest to just how humbling these patients can be to anyone who thinks he/she can intubate any human being with a Miller 2 blade or anyone who thinks they are really that good/the best with Fiberoptic intubations.

At least 5 times in my career a surgical airway was the method used to obtain successful ETT/Trach placement. That plan, no matter how good you think you are, should be included in your thought process for dealing with these types of patients.