Awake FOB not being used as much?

[RxBoy]

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In the day in age of video assisted larynoscopy, LMAs, ect. How many of you error on the side of caution and still use awake FOB for a perceived difficult airway? Not the absolute indication, but the teetering on a very thin line airway.

The other day I had a Roux-en-y with a patient in the BMI 60+ crowd, no FRC and 88% on RA with no previous intubating surgeries. Sleep study showed over 200 hypopneic/apenic episodes with a desat to lower 50s during one of the episodes.The guy had the bull frog like neck, MP IV, limited neck extension, poor oral opening, and huge tounge. Attending told me we will ramp the patient, preoxygenation with the vaders and CPAP, RSI with the planned sequence of glidescope-> Fast track LMA ventilate then blind intubation->Bronch through LMA and intubate-> last ditch resort ventilate with LMA until he wakes back up->awake FOB (all equipement ready to go in the room). We proceeded, 150 lido, 200 prop, 200 sux, no opiates fasiculations in 20 seconds -> I used the Glidescope and was able to intubate in less then 10 seconds. By the time I was bagging the guy he was already in the upper 80's. Got him back up quick and proceeded.

I thought that was kind of ballsy but it worked. If the assumption of being able to ventilate with the LMA was wrong, he def would of been dead. Emergency trach with his neck would of took at least 15 minutes and forget crico/jet ventilation. This dude was also def not a candidate for any invasive upper airway blocks (seeing as I couldn't even assess his TMD thanks to the neck fat) except down the oral route. I highly doubt he would of tolerated an awake FOB very well.

Would anyone of done this differently?

Anyone have any experience with the SV with Sevo induction technique, take a look with glidescope once deep, and intubate vs. wake back up? I see it mentioned in Miller and Barash but have never had the opportunity to try it.

 

[drccw]

In the day in age of video assisted larynoscopy, LMAs, ect. How many of you error on the side of caution and still use awake FOB for a perceived difficult airway? Not the absolute indication, but the teetering on a very thin line airway.

The other day I had a Roux-en-y with a patient in the BMI 60+ crowd, no FRC and 88% on RA with no previous intubating surgeries. Sleep study showed over 200 hypopneic/apenic episodes with a desat to lower 50s during one of the episodes.The guy had the bull frog like neck, MP IV, limited neck extension, poor oral opening, and huge tounge. Attending told me we will ramp the patient, preoxygenation with the vaders and CPAP, RSI with the planned sequence of glidescope-> Fast track LMA ventilate then blind intubation->Bronch through LMA and intubate-> last ditch resort ventilate with LMA until he wakes back up->awake FOB (all equipement ready to go in the room). We proceeded, 150 lido, 200 prop, 200 sux, no opiates fasiculations in 20 seconds -> I used the Glidescope and was able to intubate in less then 10 seconds. By the time I was bagging the guy he was already in the upper 80's. Got him back up quick and proceeded.

I thought that was kind of ballsy but it worked. If the assumption of being able to ventilate with the LMA was wrong, he def would of been dead. Emergency trach with his neck would of took at least 15 minutes and forget crico/jet ventilation. This dude was also def not a candidate for any invasive upper airway blocks (seeing as I couldn't even assess his TMD thanks to the neck fat) except down the oral route. I highly doubt he would of tolerated an awake FOB very well.

Would anyone of done this differently?

Anyone have any experience with the SV with Sevo induction technique, take a look with glidescope once deep, and intubate vs. wake back up? I see it mentioned in Miller and Barash but have never had the opportunity to try it.

Sounds like you guys had Plans A, B, C, D, E... etc...

All very reasonable...

The can't intubate, can't ventilate crowd is getting fewer and fewer with the use of video laryngoscopy and LMAs.. I've only done one awake FOB in the last 5 years, and it was for a C-spine case that the surgeon wanted to check neuro function after intubation....

One thing that I have done a couple of time is heavy topicilazation with lidocaine, then the awake look with the video laryngoscope... I like this because theortically if you're not happy with your awake look, the transition to awake FOB is easy and you don't waste any time waiting for the local to kick in..

drccw

 

[RabbMD]

For straight difficult airways i now tend to topicalize well, and then take an awake look with a glidescope. If i see cords or think it looks easy we go to sleep abd intubate. If it looks tough still it becomes awake fiberoptic. Howver, since i have started doing this, i have not had one that looked difficult via awake glidescope look. If the difficulty was masses instead of anatomy i still do awake fiberoptics, usually nasal.

 

[pgg]

Can't argue with success.


I hope AFOIs are like riding bicycles, because I've only done a handful in the last two years. Every couple months I'll do an asleep FOI just to make sure I remember how to use the scope.

It's not the fat people with thick necks and small mouths that seem to be problems - usually ventilation isn't too difficult. The airways I fear are the ones with altered anatomy. Neck masses, s/p radiation, syndrome kids (not that I do any weird peds any more).

The last two awake airways I did were in people with supraglottic masses where I didn't want plans A or B to involve putting anything in there blind and stirring up a mess. One I ended up bailing on and we awake trach'd her, the other was uneventful.

Anyone have any experience with the SV with Sevo induction technique, take a look with glidescope once deep, and intubate vs. wake back up? I see it mentioned in Miller and Barash but have never had the opportunity to try it.

I think any technique that maintains spontaneous ventilation should be safe, whether that's an inhalation induction with sevo, or topicalization + ketamine + "awake" look, or whatever.

 

[RxBoy]

For straight difficult airways i now tend to topicalize well, and then take an awake look with a glidescope. If i see cords or think it looks easy we go to sleep abd intubate. If it looks tough still it becomes awake fiberoptic. Howver, since i have started doing this, i have not had one that looked difficult via awake glidescope look. If the difficulty was masses instead of anatomy i still do awake fiberoptics, usually nasal.

Thanks for the response guys. I haven't done too many awake FOB cases wrapping up my CA1 year and now I don';t feel so bad (only 3). I did have multiple attendings let me do asleep ones which I had to do a least 5 to get that midline, clear the redundant tissue/see something more than red feel. And I still don't feel confident but I still have 2 years.

I like the localize the airway and take a look technique. Never seen it in practice but the transition to awake FOB would be smooth. The only awake FOB I have done that went super smooth was when I did a transtracheal and superior laryngeal nerve block. Patient didn't even buck. I find the 4% lido neub, benzocaine spray, and viscous lidocaine never seems to work well. The patient is always bucking, coughing, pushing the bronch scope all over the place with their tongue. Any tips for a good noninvasive upper airway block? or maybe they just tolerate the glidescope better seeing as its not stimulating the glottis and you have more power/control.

 

[deleted126335]

In the day in age of video assisted larynoscopy, LMAs, ect. How many of you error on the side of caution and still use awake FOB for a perceived difficult airway? Not the absolute indication, but the teetering on a very thin line airway.

The other day I had a Roux-en-y with a patient in the BMI 60+ crowd, no FRC and 88% on RA with no previous intubating surgeries. Sleep study showed over 200 hypopneic/apenic episodes with a desat to lower 50s during one of the episodes.The guy had the bull frog like neck, MP IV, limited neck extension, poor oral opening, and huge tounge. Attending told me we will ramp the patient, preoxygenation with the vaders and CPAP, RSI with the planned sequence of glidescope-> Fast track LMA ventilate then blind intubation->Bronch through LMA and intubate-> last ditch resort ventilate with LMA until he wakes back up->awake FOB (all equipement ready to go in the room). We proceeded, 150 lido, 200 prop, 200 sux, no opiates fasiculations in 20 seconds -> I used the Glidescope and was able to intubate in less then 10 seconds. By the time I was bagging the guy he was already in the upper 80's. Got him back up quick and proceeded.

I thought that was kind of ballsy but it worked. If the assumption of being able to ventilate with the LMA was wrong, he def would of been dead. Emergency trach with his neck would of took at least 15 minutes and forget crico/jet ventilation. This dude was also def not a candidate for any invasive upper airway blocks (seeing as I couldn't even assess his TMD thanks to the neck fat) except down the oral route. I highly doubt he would of tolerated an awake FOB very well.

Would anyone of done this differently?

Anyone have any experience with the SV with Sevo induction technique, take a look with glidescope once deep, and intubate vs. wake back up? I see it mentioned in Miller and Barash but have never had the opportunity to try it.

Big thumbs down on the sevo induction on this patient. I think the attending's plan is fine. I also think that awake F.O. is fine and would be an excellent case for a resident to hone his F.O. skills on. I have never been able to not at least squeak enough oxygen in with a LMA on this type of patient. Might need someone doing a 2 handed jaw thrust with the LMA in while someone else squeezes the bag.

I definitely do fewer awake FO than I used to, thanks to the glide scope. But still do one every few months or so. Last three have been for C-spine issues and one humongous thyroid that the patient could not lay flat for. Don't neglect getting trained in the technique.

 

[2win]

In the day in age of video assisted larynoscopy, LMAs, ect. How many of you error on the side of caution and still use awake FOB for a perceived difficult airway? Not the absolute indication, but the teetering on a very thin line airway.

The other day I had a Roux-en-y with a patient in the BMI 60+ crowd, no FRC and 88% on RA with no previous intubating surgeries. Sleep study showed over 200 hypopneic/apenic episodes with a desat to lower 50s during one of the episodes.The guy had the bull frog like neck, MP IV, limited neck extension, poor oral opening, and huge tounge. Attending told me we will ramp the patient, preoxygenation with the vaders and CPAP, RSI with the planned sequence of glidescope-> Fast track LMA ventilate then blind intubation->Bronch through LMA and intubate-> last ditch resort ventilate with LMA until he wakes back up->awake FOB (all equipement ready to go in the room). We proceeded, 150 lido, 200 prop, 200 sux, no opiates fasiculations in 20 seconds -> I used the Glidescope and was able to intubate in less then 10 seconds. By the time I was bagging the guy he was already in the upper 80's. Got him back up quick and proceeded.

I thought that was kind of ballsy but it worked. If the assumption of being able to ventilate with the LMA was wrong, he def would of been dead. Emergency trach with his neck would of took at least 15 minutes and forget crico/jet ventilation. This dude was also def not a candidate for any invasive upper airway blocks (seeing as I couldn't even assess his TMD thanks to the neck fat) except down the oral route. I highly doubt he would of tolerated an awake FOB very well.

Would anyone of done this differently?

Anyone have any experience with the SV with Sevo induction technique, take a look with glidescope once deep, and intubate vs. wake back up? I see it mentioned in Miller and Barash but have never had the opportunity to try it.

Good that worked for you . And your attending.
What is the second plan for " I cannot ventilate"???
What is the evidence based study to show the relation between intubation and "hypopneic /apneic" episodes? Numbers....
Otherwise fine.
I don't take chances. Either I can ventilate ( and whatever) or I can't.

 

[cchoukal]

I have a very low threshold to intubate awake, be it DL (in the ICU) or FOB. I have extolled the virtues of the awake intubation in numerous posts before. The typical OR scenarios would be a guy with a stigmata of a difficult intubation coupled with either significant reflux disease or signs of difficult ventilation.

I think the Glide is a wonderful tool and I think the awake look with this is really reasonable.

A couple notes on what some of the posters above have said:

I tend to do my awake FOBIs in the seated position, approaching the patient from the front (no, I'm not a pulmonologist). Seems to be more comfortable/less frightening for the patient and maybe reduces some of the tissue redundancy that occurs in the supine position.

I have sworn off benzocaine altogether. I know the review articles suggest the paste doesn't cause Met-Hb as often as the spray, but 1) I just had a case of it, and 2) a very brief lit search reveals dozens of case reports with the paste.

I have recently started doing transtracheal blocks (technically, I aim for the cricothyroid membrane) and I have been very happy with the results. MUCH less coughing once the tube is in place. In fact, I recently did one in a patient and he was so comfortable after the tube was in, instead of inducing him and moving his 400 lb body from the gurney to the table, he was able to do it himself

 

[RxBoy]

Good that worked for you . And your attending.
What is the second plan for " I cannot ventilate"???
What is the evidence based study to show the relation between intubation and "hypopneic /apneic" episodes? Numbers....
Otherwise fine.
I don't take chances. Either I can ventilate ( and whatever) or I can't.

That was the point... The second plan for cannot ventilate was LMA and if that didn't work the patient would of been dead. Hence why it was risky.

The mention of "hypopneic /apneic" episodes was nearly to illustrate the severity of the patient's OSA and chances are he would desaturate extremely quick. Although snoring is an independent risk factor for difficulty ventilating, I never said anything about it being associated with a difficult intubation.

I am not entirely sure what the point of your post was... I clearly stated it was risky (specifically ballsy). I am guessing you are stating that you would of did an awake FOBI.

 

[Jeff05]

this is not the population you need to worry about. although i can tell you that you would not be able to effectively ventilate that patient with an LMA as it would not be able to maintain a seal that could hold the peak pressures you would need.

if that guy coded you would have expert witnesses lining out the door to testify against you.


patients with head and neck tumors/history of radiation to neck - these are the patients that may not lend themselves to videoscopes - as their tissue may not be deformable. these patients may be impossible to ventilate and not lend themselves to proper LMA placement for the same reason.

learn how to do a slick awake FO.

 

[annie5644]

What size Glidescope handle are you guys using? I have found the #3 to be too small in most medium/large-sized male patients.

 

[RxBoy]

this is not the population you need to worry about. although i can tell you that you would not be able to effectively ventilate that patient with an LMA as it would not be able to maintain a seal that could hold the peak pressures you would need.

if that guy coded you would have expert witnesses lining out the door to testify against you.


patients with head and neck tumors/history of radiation to neck - these are the patients that may not lend themselves to videoscopes - as their tissue may not be deformable. these patients may be impossible to ventilate and not lend themselves to proper LMA placement for the same reason.

learn how to do a slick awake FO.

Good point. Through the ET tube the guy required peaks to the lower 40's. Once they insuffulated the belly it jumped to the 50s so I switched to PC of 30 with Peep of 10. Pulled good TVs but the ETCO2 was in the mid 40s. I am guessing thats where the guy lived anyways. Thank god gastric bypasses require rTberg.

LMAs would leak in the 30s but a least some O2 would be getting in there. I wouldn't be too concerned about adequate ventilation seeing as CO2 would probably get to a maximum of 70s before he woke up. But like you said, if he coded, it would of been a lawyers wet dream.

 

[Jeff05]

Good point. Through the ET tube the guy required peaks to the lower 40's. Once they insuffulated the belly it jumped to the 50s so I switched to PC of 30 with Peep of 10. Pulled good TVs but the ETCO2 was in the mid 40s. I am guessing thats where the guy lived anyways. Thank god gastric bypasses require rTberg.

LMAs would leak in the 30s but a least some O2 would be getting in there. I wouldn't be too concerned about adequate ventilation seeing as CO2 would probably get to a maximum of 70s before he woke up. But like you said, if he coded, it would of been a lawyers wet dream.

LMAs leak at 18-20. that wouldn't be enough to ventilate this guy's dead space.

Only LMA Supreme is rated for pressures of 30cm H20.

 

[countingdays]

LMAs leak at 18-20. that wouldn't be enough to ventilate this guy's dead space.

Only LMA Supreme is rated for pressures of 30cm H20.

I think the point is that even limited ventilation would buy you time to attempt intubation through the lma with and without a scope, or to do a challenging cric or wake up before you get hypoxic injury. No one is suggesting prolonged inadequate ventilation or proceeding with surgery with the lma in place in this guy.

 

[Jeff05]

I think the point is that even limited ventilation would buy you time to attempt intubation through the lma with and without a scope, or to do a challenging cric or wake up before you get hypoxic injury. No one is suggesting prolonged inadequate ventilation or proceeding with surgery with the lma in place in this guy.

my point is that there would be essentially NO ventilation or oxygenation. how many crash crics have you done on pts with BMI 60? how successful do you think that would be?

how long would it take you to successfully intubate through an LMA? how about during chest compressions?

think about this guy's CO2 production (gonna go up by much more than 6 first minute and 3 after) and the resultant acute change in pH.

more importantly, think about this guy's O2 use - 3-4ml/kg/min. he has essentially NO FRC. next time you put a morbidly obese patient to sleep see how long it takes them to desat after a full preoxygenation.

this guy is not going to just wake up or start breathing with a CO2 of 80 and a sat of 60. he will be obstructed and apneic.

 

[Idiopathic]

Good point. Through the ET tube the guy required peaks to the lower 40's. Once they insuffulated the belly it jumped to the 50s so I switched to PC of 30 with Peep of 10. Pulled good TVs but the ETCO2 was in the mid 40s. I am guessing thats where the guy lived anyways. Thank god gastric bypasses require rTberg.

LMAs would leak in the 30s but a least some O2 would be getting in there. I wouldn't be too concerned about adequate ventilation seeing as CO2 would probably get to a maximum of 70s before he woke up. But like you said, if he coded, it would of been a lawyers wet dream.

this guy isnt spontaneously waking up if you put him to sleep and cant get the airway. his paCO2 is probably in the mid 50s at baseline, sats going down to <60 QUICKLY with inadequate ability to oxygenate combined with CO2>80 due to same soon equals bradycardia and arrest. wake this patient up cannot be in your plan because its not likely to happen.

edit: i see jeff and i are on the same page

 

[mghanesres]

But like you said, if he coded, it would of been a lawyers wet dream.

Would HAVE been, yes. 😉 (Not would "of" been. Sorry... pet peeve.)

 

[countingdays]

my point is that there would be essentially NO ventilation or oxygenation. how many crash crics have you done on pts with BMI 60? how successful do you think that would be?

how long would it take you to successfully intubate through an LMA? how about during chest compressions?

think about this guy's CO2 production (gonna go up by much more than 6 first minute and 3 after) and the resultant acute change in pH.

more importantly, think about this guy's O2 use - 3-4ml/kg/min. he has essentially NO FRC. next time you put a morbidly obese patient to sleep see how long it takes them to desat after a full preoxygenation.

this guy is not going to just wake up or start breathing with a CO2 of 80 and a sat of 60. he will be obstructed and apneic.

30 seconds or so with a tube loaded onto a powered-up fiberoptic through an intubating lma.

I'm not sure why you say there would be no ventilation. You may not be moving tidal volumes of 600, but you could slow the desat even with low Vt, rapid breaths. Sure you're CO2 will be climbing, but at less that 3/minute since you are ventilating some.

I'd be interested in reading any studies about bmi cutoffs for lma's if you all know of any. I'm looking for something right now.

 

[Arch Guillotti]

I'm not sure why you say there would be no ventilation. You may not be moving tidal volumes of 600, but you could slow the desat even with low Vt, rapid breaths. Sure you're CO2 will be climbing, but at less that 3/minute since you are ventilating some.

I'd be interested in reading any studies about bmi cutoffs for lma's if you all know of any. I'm looking for something right now.

Maybe, but what of you can't ventilate at all?

I am not aware of a "cutoff" for LMA's. I have used them on some pretty hefty patients but the procedure has to be quick and it has to seat pretty darn good.

 

[Arch Guillotti]

In the day in age of video assisted larynoscopy, LMAs, ect. How many of you error on the side of caution and still use awake FOB for a perceived difficult airway? Not the absolute indication, but the teetering on a very thin line airway.

The other day I had a Roux-en-y with a patient in the BMI 60+ crowd, no FRC and 88% on RA with no previous intubating surgeries. Sleep study showed over 200 hypopneic/apenic episodes with a desat to lower 50s during one of the episodes.The guy had the bull frog like neck, MP IV, limited neck extension, poor oral opening, and huge tounge. Attending told me we will ramp the patient, preoxygenation with the vaders and CPAP, RSI with the planned sequence of glidescope-> Fast track LMA ventilate then blind intubation->Bronch through LMA and intubate-> last ditch resort ventilate with LMA until he wakes back up->awake FOB (all equipement ready to go in the room). We proceeded, 150 lido, 200 prop, 200 sux, no opiates fasiculations in 20 seconds -> I used the Glidescope and was able to intubate in less then 10 seconds. By the time I was bagging the guy he was already in the upper 80's. Got him back up quick and proceeded.

I thought that was kind of ballsy but it worked. If the assumption of being able to ventilate with the LMA was wrong, he def would of been dead. Emergency trach with his neck would of took at least 15 minutes and forget crico/jet ventilation. This dude was also def not a candidate for any invasive upper airway blocks (seeing as I couldn't even assess his TMD thanks to the neck fat) except down the oral route. I highly doubt he would of tolerated an awake FOB very well.

Would anyone of done this differently?

Anyone have any experience with the SV with Sevo induction technique, take a look with glidescope once deep, and intubate vs. wake back up? I see it mentioned in Miller and Barash but have never had the opportunity to try it.

Your attending is either very ballsy or a blame fool. I am not sure which is a better description.

If he can't tolerate an awake fiber very well then you aren't doing it right. Excellent scope and tube tolerance can be achieved without using needles for blocks.

I think the awake fiber is not as prevalent with all the gadgets that we have now but still a skill that you need to have.

With the info that you presented I would have done an awake intubation.

 

[countingdays]

I'm in peds so I don't do stuff like this at all right now. I just think it's an interesting discussion. I may find myself taking care of morbidly obese adults in the future. I get the point about being up s++t creek IF you can't ventilate through it at all and can't do an asleep fiberoptic quickly through the lma. I just wonder how likely that is.


Anesth Analg. 2002 Mar;94(3):737-40; table of contents.
The Laryngeal Mask Airway ProSeal(TM) as a temporary ventilatory device in grossly and morbidly obese patients before laryngoscope-guided tracheal intubation.
Keller C, Brimacombe J, Kleinsasser A, Brimacombe L.
Source
Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria.
Abstract
We determined the efficacy of the laryngeal mask airway ProSeal(TM) (PLMA) as a temporary ventilatory device in morbidly obese patients before laryngoscope-guided tracheal intubation. Sixty patients (body mass index 35--60 kg/m(2)) scheduled for elective surgery, who preferred airway management under general anesthesia, were studied. The induction of anesthesia was with midazolam/fentanyl/propofol and maintenance was with sevoflurane 1%--3% in oxygen 100%. The PLMA was inserted and an effective airway established. Rocuronium was given IV for paralysis. Oropharyngeal leak pressure, ease of gastric tube placement, residual gastric volume, fiberoptic position of the airway/drainage tube, and ease of ventilation at a tidal volume of 8 mL/kg was determined. The PLMA was then removed and laryngoscope-guided tracheal intubation attempted. The number of insertion/intubation attempts (maximum two each) and time taken to establish an effective airway with each device were recorded. An effective airway was obtained at the first insertion attempt in 90% of patients (54/60) and at the second attempt in 10% (6/60). The time taken to provide an effective airway was 15 plus minus 7 s (7--42 s). Oropharyngeal leak pressure was 32 plus minus 8 cm H(2)O (12--40 cm H(2)O). The residual gastric volume was 36 plus minus 46 mL (0--240 mL). Positive pressure ventilation without air leaks was possible in 95% of patients (57/60). The vocal cords were seen from the airway tube in 75% of patients (45/60), but the esophagus was not seen. The fiberoptic view from the drainage tube revealed mucosa in 93% of patients (56/60) and an open upper esophageal sphincter in 7% (4/60). Tracheal intubation was successful at the first attempt in 90% of patients (54/60), at the second attempt in 7% (4/60), and failed in 3% (2/60). In these latter two patients, the PLMA was reinserted and surgery performed uneventfully with the PLMA. The time taken to tracheally intubate the patient was 13 plus minus 10 s (8--51 s). There were no episodes of hypoxia (SpO(2) <90%) or other adverse events. There were no differences in insertion success rate, or the time to successful insertion between the PLMA and laryngoscope-guided intubation. We conclude that the PLMA is an effective temporary ventilatory device in grossly or morbidly obese patients before laryngoscope-guided tracheal intubation. IMPLICATIONS: The laryngeal mask airway ProSeal(TM) is an effective temporary ventilatory device in grossly and morbidly obese patients before laryngoscope-guided tracheal intubation.

 

[kmurp]

First of all, excuse my ignorance: what's a "vader"?
I use the bronchoscope as much as ever. I without a doubt would have done so here. What in gods name is the downside? I can think of plenty of downside with the approach you used. It shows a lot of hubris.

 

[Arch Guillotti]

this guy isnt spontaneously waking up if you put him to sleep and cant get the airway. his paCO2 is probably in the mid 50s at baseline, sats going down to <60 QUICKLY with inadequate ability to oxygenate combined with CO2>80 due to same soon equals bradycardia and arrest. wake this patient up cannot be in your plan because its not likely to happen.

edit: i see jeff and i are on the same page

yeah I think that waking this guy up is for all intents and purposes a bad plan

 

[Arch Guillotti]

Big thumbs down on the sevo induction on this patient.

Agree, I would stay away from a mask induction. Oft-quoted, rarely done in my experience.

 

[aneftp]

I have a very low threshold to intubate awake, be it DL (in the ICU) or FOB. I have extolled the virtues of the awake intubation in numerous posts before. The typical OR scenarios would be a guy with a stigmata of a difficult intubation coupled with either significant reflux disease or signs of difficult ventilation.

I think the Glide is a wonderful tool and I think the awake look with this is really reasonable.

A couple notes on what some of the posters above have said:

I tend to do my awake FOBIs in the seated position, approaching the patient from the front (no, I'm not a pulmonologist). Seems to be more comfortable/less frightening for the patient and maybe reduces some of the tissue redundancy that occurs in the supine position.

I have sworn off benzocaine altogether. I know the review articles suggest the paste doesn't cause Met-Hb as often as the spray, but 1) I just had a case of it, and 2) a very brief lit search reveals dozens of case reports with the paste.

I have recently started doing transtracheal blocks (technically, I aim for the cricothyroid membrane) and I have been very happy with the results. MUCH less coughing once the tube is in place. In fact, I recently did one in a patient and he was so comfortable after the tube was in, instead of inducing him and moving his 400 lb body from the gurney to the table, he was able to do it himself

I agree. Really just do transtracheal and superior larygneal (they are so easy) if I am just doing nasal fiberoptic. Maybe still spray a little benzo in the mouth if it's awake intubation is through the mouth.

I've seen too many "team care" approaches getting the false sense of security that since's there is one MD plus one crna/aa/resident that they should be able to secure the airway.

Having worked both in MD only and team models, I find team models take way too many chances with the airway.

I had this patient a couple months ago, he's been a known difficult intubation not one, two BUT 3 difficult intubations. The group that keeps on intubating (or trying to ) is a team care model. Just because he's a skinny guy (weights 160 pounds), they figure they can get away with it.

Don't get me wrong, I love the glide scope. It's really improved airway outcomes. But we just need to use common sense here. We may be able to hand mask/LMA f a 400 pounder for a while but if he goes down that steep path where he's retaining too much CO2, any artificial airway will be needed to be place, whether ET tube or surgical airway. Do we want to risk patient safety and just be cavalier about it?

 

[dhb]

Agree, I would stay away from a mask induction. Oft-quoted, rarely done in my experience.

I've done it in a post radiation neck surgery patient and it worked great. She was skinny and would have been easy to ventilate.
I would not use this technique in an obese patient.

 

[pgg]

Agree, I would stay away from a mask induction. Oft-quoted, rarely done in my experience.

Especially in stupendously obese people - it's going to take f o r e v e r to get them deep enough to do anything, and maintaining SV doesn't mean they won't obstruct the way they always do when they go to sleep in their beds at home.

Having worked both in MD only and team models, I find team models take way too many chances with the airway.

Huh. Why do you think that is?

I see the flip side to that with independent CRNAs. Practically none of them have ever done an AFOI. Plan A is a Glidescope, and I guess plan B is an LMA or wakeup. Compounding the issue is that very few know any non-spinal regional techniques to avoid the airway. I have never once ever seen one of my fully credentialled independent colleagues out at the local hospital so much as touch a fiberoptic scope. (Inside the military it's a bit different, since the military-trained CRNAs do get SOME fiberoptic time and lots of regional training.)

I don't do many FOIs but I sure consider them anytime things look hinky.

 

[Idiopathic]

First of all, excuse my ignorance: what's a "vader"?
I use the bronchoscope as much as ever. I without a doubt would have done so here. What in gods name is the downside? I can think of plenty of downside with the approach you used. It shows a lot of hubris.

patient refuses

patient doesnt tolerate

"a little" sedation turns into snoring followed by laryngospasm/bronchospasm

 

[aneftp]

I know. I think fiberoptic intubation is becoming a lost art. But anyone can learn it.

I was taught fiberoptic during training first with asleep patients. Just get one of your attendings to let u play with the fiberoptic in an Asa 1-2 skinny hysterectomy patient where u may have 3-4 minutes to fiddle around. That's how you start learning.

It's like a video gane. If you are good with video games, handling a fiberoptic scope should be easy.

With anything in medicine, practice practice practice.

The classic teaching used to be take two DL looks and wake up the patient for a fiberoptic (to avoid a bloody airway).

Now so many are taught to just go straight to the glide scope.

 

[imfrankie]

30 seconds or so with a tube loaded onto a powered-up fiberoptic through an intubating lma.

I'm not sure why you say there would be no ventilation. You may not be moving tidal volumes of 600, but you could slow the desat even with low Vt, rapid breaths. Sure you're CO2 will be climbing, but at less that 3/minute since you are ventilating some.

I'd be interested in reading any studies about bmi cutoffs for lma's if you all know of any. I'm looking for something right now.

Biggest guy in the literature (as of a couple years ago) was intubated by: first swallow LMA, then FOB loaded with ventilating tube changer, then tube over the changer. Big ole guy. They had a picture.

 

[imfrankie]

Biggest guy in the literature (as of a couple years ago) was intubated by: first swallow LMA, then FOB loaded with ventilating tube changer, then tube over the changer. Big ole guy. They had a picture.

I would do very very little sedation awake fiber. Like Benumof says: you just gotta take the time to get buy-in from the patient. Explain that you don't want to kill him. Cooperation follows.

People swallow LMAs awake, the guy at the Difficult Airway workshop fibers himself every show (very good course btw). Do that stuff awake if you're concerned. I'm telling you the hired gun expert witness will chop your head off.

I have to agree it's very easy to get sucked in to balsy maneuvers when you have an extra pair of hands. I've been there too. Be careful youngsters. Once you get burned the scar is there forever.

 

[Idiopathic]

I would do very very little sedation awake fiber. Like Benumof says: you just gotta take the time to get buy-in from the patient. Explain that you don't want to kill him. Cooperation follows.

People swallow LMAs awake, the guy at the Difficult Airway workshop fibers himself every show (very good course btw). Do that stuff awake if you're concerned. I'm telling you the hired gun expert witness will chop your head off.

I have to agree it's very easy to get sucked in to balsy maneuvers when you have an extra pair of hands. I've been there too. Be careful youngsters. Once you get burned the scar is there forever.

as they should. if you are worried about a patient or have a patient with EVERY WARNING SIGN (such as this one) not just for a difficult intubation/ventilation, but for an poor likelihood of tolerating that difficulty and you dont have the soundest reasoning to back up your decision then you wouldnt be able to defend yourself against a 4-year old holding up the ASA airway algorithm, much less someone asking pointed questions.

 

[Arch Guillotti]

I've done it in a post radiation neck surgery patient and it worked great. She was skinny and would have been easy to ventilate.
I would not use this technique in an obese patient.

uh, if you thought she was easy to ventilate why didn't you just put her to sleep?

Just because someone is skinny doesn't mean they are easy to ventilate. Some of the worst airways can be the skinny old dudes with head and neck cancer who have been irradiated or operated on.

 

[cleansocks]

1. possible can't intubate and possible can't mask ventilate: definitely awake FOB. Shouldn't plan to have to depend on LMA.
2. possibly can't intubate or ventilate but very likely can do the other: riskier strategies with newer toys are then OK.

My institution has these HUGE fiberoptic carts... they call them "towers." I wish they'd make a fiberoptic scope cart the size of a glidescope/CMAC cart. I'd use something like that for scenario number 2 all the time if they could actually fit in the OR's easily!

 

[seinfeld]

I dont do many ENT extreme cases, but in 2 years of PP i have not used an AFOI. Glidescope all the way, have done multiple ICU intubations on 300kg pts without struggle.

 

[Lightwand]

uh, if you thought she was easy to ventilate why didn't you just put her to sleep?

Just because someone is skinny doesn't mean they are easy to ventilate. Some of the worst airways can be the skinny old dudes with head and neck cancer who have been irradiated or operated on.

Agree x 1,000,000. The only time I have had to go all the way to the end of the airway algorithm was in a 50kg guy with head/neck CA who was s/p XRT. And that was in a patient who was spontaneously ventilating, until he suddenly wasn't able to be ventilated.

I've got to agree with those who would have done an AFOI in your patient, OP. Why not? Not worth the risk of going to sleep, in my book. Lots of people play this game every day, and most of the time you're going to get lucky and not run into any issues. But if you gamble enough, you're going to end up on the losing end eventually...

 

[Idiopathic]

yes, cases like this define the saying "the plural of anecdote is not data". i feel like this is a great story but that if you take the same course with a patient just like this 100 times, then you will get into trouble 1 to 5 times and thats too high for an elective procedure. its nice that this worked and id keep it in my back pocket for similar situations, but the picture you paint for me is one of a patient that needed to be awake for intubation, not just for the mallampatti class, either.

 

[RxBoy]

yes, cases like this define the saying "the plural of anecdote is not data". i feel like this is a great story but that if you take the same course with a patient just like this 100 times, then you will get into trouble 1 to 5 times and thats too high for an elective procedure. its nice that this worked and id keep it in my back pocket for similar situations, but the picture you paint for me is one of a patient that needed to be awake for intubation, not just for the mallampatti class, either.

I think this is a great point, it's nice to see a survey of different perspectives. In all honesty I don't think my attending had the intention to wake the patient up. In his head we were going to intubate one way or another. I work with attendings who always err on the side of caution, others that take risks. That particular attending is the risk taker type. My gut told me he needed an AFOBI. Even brought it up but he told me the guy would probably not tolerate it very well and it wasn't an absolute indication (thinking to myself then what the hell is?). I guess one of the beauties of residency is that you see so many different approaches to the same problem, you begin to find your own skill/comfort level.

Lots of good input in this thread. One reoccurring theme, be very careful with those head/neck cancers. Haven't encountered too many yet but when I do Ill remember to be extra cautious. Curious... If a planned afobi is unsuccessful, is the last ditch resort for surgery an awake trach under local? I mean if its an urgent surgery they're going to need an airway one way or another.

Ps: vaders = slang for airway straps.

 

[RxBoy]

My institution has these HUGE fiberoptic carts... they call them "towers." I wish they'd make a fiberoptic scope cart the size of a glidescope/CMAC cart. I'd use something like that for scenario number 2 all the time if they could actually fit in the OR's easily!

Totally agree. Mine does too. I mean anything FO is synonymous with a difficult airway cart. I understand the need when things get ugly during an induction but afobi needs only a battery operated scope, 3 parker flex tip tubes, lubricant, and maybe some airway block supplies. No need for a 500 lb cart that takes up half the OR.

 

[fakin' the funk]

We proceeded, 150 lido, 200 prop, 200 sux, no opiates fasiculations in 20 seconds

To be frank, I think trying to wait for this patient to wake up if you are in a CV/CI situation, after the aforementioned induction, is totally ******ed. Benumof's data will show you that desaturation happens WAY before the sux and propofol are gone.

I think all the pro-Glidescope sentiment in this group suggests that we think this is a patient who will be difficult to ventilate, but not necessarily to intubate. You wisely skipped the ventilation step in Plan A, but all your backup plans involved ventilation.

Ventilation (spontaneous or positive-pressure) is gonna hurt you here, and so I agree with others that sevoflurane inhalation induction is a bad idea. On skinny people this is kind of a cool technique though (sevo -> DL, no NMB needed)

The more I think about this scenario, the better an awake technique sounds.

 

[RxBoy]

To be frank, I think trying to wait for this patient to wake up if you are in a CV/CI situation

That wasn't the plan. If u read the post, you would of understood that. The point was if it turned into a CI but can ventilate then we would wake up. If it was CV/CI that patient would of been dead hence why it was risky. LMA would of been more for oxygenation (possibly apenic) then ventilation, and facilitation for fast track Blind or FOB. We weren't planning on running the case with an LMA with adequate ventilation as someone previously posted. Just a crutch for some oxygenation.

 

[jetproppilot]

In the day in age of video assisted larynoscopy, LMAs, ect. How many of you error on the side of caution and still use awake FOB for a perceived difficult airway? Not the absolute indication, but the teetering on a very thin line airway.

The other day I had a Roux-en-y with a patient in the BMI 60+ crowd, no FRC and 88% on RA with no previous intubating surgeries. Sleep study showed over 200 hypopneic/apenic episodes with a desat to lower 50s during one of the episodes.The guy had the bull frog like neck, MP IV, limited neck extension, poor oral opening, and huge tounge. Attending told me we will ramp the patient, preoxygenation with the vaders and CPAP, RSI with the planned sequence of glidescope-> Fast track LMA ventilate then blind intubation->Bronch through LMA and intubate-> last ditch resort ventilate with LMA until he wakes back up->awake FOB (all equipement ready to go in the room). We proceeded, 150 lido, 200 prop, 200 sux, no opiates fasiculations in 20 seconds -> I used the Glidescope and was able to intubate in less then 10 seconds. By the time I was bagging the guy he was already in the upper 80's. Got him back up quick and proceeded.

I thought that was kind of ballsy but it worked. If the assumption of being able to ventilate with the LMA was wrong, he def would of been dead. Emergency trach with his neck would of took at least 15 minutes and forget crico/jet ventilation. This dude was also def not a candidate for any invasive upper airway blocks (seeing as I couldn't even assess his TMD thanks to the neck fat) except down the oral route. I highly doubt he would of tolerated an awake FOB very well.

Would anyone of done this differently?

Anyone have any experience with the SV with Sevo induction technique, take a look with glidescope once deep, and intubate vs. wake back up? I see it mentioned in Miller and Barash but have never had the opportunity to try it.

Sorry to add something not related to the corollary, but it needs to be added.

The

BOUGIE

Has changed our business.

Also called the Eschman,

and I'm sure I spelled it wrong.

Being able to visualize just enough but not enough to pass an endotracheal tube but enough to pass a stylette like thinghy and then Seldinger the tube over the stylette

reduced the fiberoptic need by about 99%.

 

[Mman]

I think I've done 2 or 3 awake FOIs in the last 2 years. It's rare. All were on ENT patients with horrible pathology in their pharynx or previous radiation (or both).

We do lots of super fat patients (400-500 lbs is common for our gastric bypass patients and 600 isn't that rare) and the vast majority can be intubated easily with the glidescope. If you can open your mouth wide enough to get the blade in, I can nearly always get the tube in.

I also love the bougie. It makes using the Miller blade much easier by eliminating situations where you can get some sort of a view but lose it when the tube is in the mouth. Put a big old anterior bend on it and aim high and you can hit nearly anything.

Don't get me wrong, you can't be reckless in assuming you will always be able to intubate or ventilate on some of the iffy looking airways. But there are lots of ways to skin a cat and the actual number of times you will need to go awake FOI is very rare.

 

[aneftp]

Sorry to add something not related to the corollary, but it needs to be added.

The

BOUGIE

Has changed our business.

Also called the Eschman,

and I'm sure I spelled it wrong.

Being able to visualize just enough but not enough to pass an endotracheal tube but enough to pass a stylette like thinghy and then Seldinger the tube over the stylette

reduced the fiberoptic need by about 99%.

Agreed 100%. Sometimes not enough space/angle to put ET tube in with the glidescope.

For some reason, I always carry 2 bougies (the disposable ones) in my little black bag with me. It's been a lifesaver to use along with the glide scope.

 

[dhb]

If a planned afobi is unsuccessful, is the last ditch resort for surgery an awake trach under local?

Yes!

Arch i'd rather have someone in SV while i take a look w DL rather than trying to get them deep on propofol with more risk of apnea but that's just me.
Btw she was at 80% sat on RA and 80mmHg systolic so i thought it would be easier to manage just one drug (sevo) rather than propofol/vasoactive & the airway at the same time.

 

[imfrankie]

And of course...the blind nasal intubation.
A beautiful lost art.

 

[Gimlet]

1. possible can't intubate and possible can't mask ventilate: definitely awake FOB. Shouldn't plan to have to depend on LMA.
2. possibly can't intubate or ventilate but very likely can do the other: riskier strategies with newer toys are then OK.

My institution has these HUGE fiberoptic carts... they call them "towers." I wish they'd make a fiberoptic scope cart the size of a glidescope/CMAC cart. I'd use something like that for scenario number 2 all the time if they could actually fit in the OR's easily!

The Storz reps were here a couple of months ago and mentioned a fiberoptic scope attachment for the CMAC was in the works, probably within the year by now.

 

[nap$ter]

Especially in stupendously obese people - it's going to take f o r e v e r to get them deep enough to do anything, and maintaining SV doesn't mean they won't obstruct the way they always do when they go to sleep in their beds at home.


really? clearly a gas induction isn't a good idea in the gargantuan, and clearly wake-up is slower from saturation of the large fat compartment, but - is onset of anesthesia delayed in the morbidly obese with volatile anesthesia? I ask because I don't know the answer, and can't find any clinical evidence.

uptake into the fat group is increased with the size of the compartment, which delays equilibration, and wake-up, but i believe the slope and height of the steep part of the FA/Fi curve to be due primarily to - first - solubility of the gas in blood and - second - saturation of the vessel-rich group. The flatter, later part of the curve is influenced more by saturation of - third- the muscle group, and -fourth - the fat group (and the fingernails are negligible).

I wager that the onset of clinical anesthesia is not significantly different in the morbidly obese with volatile anesthesia. If I'm wrong, I would love to see the clinical studies and justification.

 

[dhb]

I refrained from posting the same thing as pgg because you could potentially get a faster wake up due to redistribution to the fat compartment...?

 

[pgg]

really? clearly a gas induction isn't a good idea in the gargantuan, and clearly wake-up is slower from saturation of the large fat compartment, but - is onset of anesthesia delayed in the morbidly obese with volatile anesthesia? I ask because I don't know the answer, and can't find any clinical evidence.

uptake into the fat group is increased with the size of the compartment, which delays equilibration, and wake-up, but i believe the slope and height of the steep part of the FA/Fi curve to be due primarily to - first - solubility of the gas in blood and - second - saturation of the vessel-rich group. The flatter, later part of the curve is influenced more by saturation of - third- the muscle group, and -fourth - the fat group (and the fingernails are negligible).

I wager that the onset of clinical anesthesia is not significantly different in the morbidly obese with volatile anesthesia. If I'm wrong, I would love to see the clinical studies and justification.

You could well be right. I'm just extrapolating the dramatically increasing inhalation induction times for kids -> adolescents -> adults, and adding in -> obese adults at the end. That may not be justifiable; I don't have a counter argument to your convincing FA/Fi curve and tissue groups.