Awake intubation: Do you ever do it, and if so, how?

[Angry Birds]

So, I'm prepping for the oral boards, and the book is talking about awake intubations. I've certainly read about this before, seen EmCrit videos, etc.-- but, I've gotta be honest: I've never done it, even on difficult airway cases.

My experience has taught me that the first pass is the most important. Each successive attempt is tougher and tougher, as the airway becomes edematous and bloody. So, I do everything I can to succeed on the first pass, and this necessarily includes good RSI.

What are your thoughts? Do you do awake intubations, and if so, how do you do it?

And, for the oral boards, how should I think about this issue? Okuda book says that I will be unsuccessful if I RSI a patient with Ludwig's angina. Will they really ding me on the exam for this?

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[TooMuchResearch]

So, I'm prepping for the oral boards, and the book is talking about awake intubations. I've certainly read about this before, seen EmCrit videos, etc.-- but, I've gotta be honest: I've never done it, even on difficult airway cases.

My experience has taught me that the first pass is the most important. Each successive attempt is tougher and tougher, as the airway becomes edematous and bloody. So, I do everything I can to succeed on the first pass, and this necessarily includes good RSI.

What are your thoughts? Do you do awake intubations, and if so, how do you do it?

And, for the oral boards, how should I think about this issue? Okuda book says that I will be unsuccessful if I RSI a patient with Ludwig's angina. Will they really ding me on the exam for this?

You probably would be successful. That book is saying some other things I disagree with, as do many textbooks. I think on the real exam if you fail RSI but cric the patient, that's still appropriate care right?

 

[Janders]

(1) It is amazing how much of a semi-awake intubation you can do with nebulizer 4% lidocaine and a whiff of prop/ketamine, and a glidescope...

(2) I'm no oral boards examiner. But you need to see the test from their view point:

Oral Board Victim-- My patient has sublingual swelling, fever, rigors, and a leukocytosis. I have ordered broad labs, IV access, a fluid bolus and broad antibiotics with UNASYN and VANCOMYCIN. I am concerned they have Ludwigs Angina.
Examiner-- Very good, your patient complains of trouble breathing.
OBV-- I pull out my Laryngoscope of 2+ badassery, swagger to the head of the bed, call for Sux and Etomidate, and first-pass intubate the bastard like the freaking hero I am!
Examiner-- the airway is massively swollen and you recognize nothing. The saturation is now 0%. The HR is now 10. The nursing staff notes no pulse. Would you like to start CPR!
OBV-- aw, crap.

They aren't looking for a hero. They are looking for a wise clinician who does things by the book.

Examiner-- Very good, your patient complains of trouble breathing.
OBV-- I am very concerned his Ludwigs is progressing and he will rapidly lose his airway. I ask the RN staff to place him on 100% non-rebreather. I ask the unit coordinator to page on-call ENT for possible surgical airway backup, and on-call anesthesia for airway backup due to the high risk of this intubation. I ask the RN staff to get the cric kit open at bedside. How is my patient now?
Examiner-- The patient appears tachypneic, struggling slightly, but the saturation is 98% on the NRB
OBV-- I do not think we have time to wait for ENT/Anesthesia to drive in. I would like to use a skin marker to mark out the area of the cricothyroid membrane, in case I need to abort my RSI and make a surgical airway. I would like to attempt to topicalize the patient with a nebulizer of 4% lidocaine. I ask the RN staff to have propofol, etomidate, and succinylcholine at bedside.
etc
etc

 

[enalli]

Do you do awake intubations, and if so, how do you do it?

Disclaimer: I'm a resident and have only done a few of these. We also don't have a fiberoptic laryngoscope in my department.

The times I've done this have been as a way to delay paralysis as long as possible because we were concerned the patient would crash immediately after losing muscle tone.

This is the way I've done it and seen it done in my department:
- Often, these are patients that we want to position "upright"
- Spray 4% lidocaine liberally in the oropharynx ahead of time
- Sedate with ketamine and have a paralytic drawn up and ready to push
- Get your view with VL
- If you can get the tube in, go ahead; if not, push the paralytic while keeping your view, then put in the tube
- Sedate

I'm interested in hearing how other places do it.

 

[Angry Birds]

Disclaimer: I'm a resident and have only done a few of these. We also don't have a fiberoptic laryngoscope in my department.

The times I've done this have been as a way to delay paralysis as long as possible because we were concerned the patient would crash immediately after losing muscle tone.

This is the way I've done it and seen it done in my department:
- Often, these are patients that we want to position "upright"
- Spray 4% lidocaine liberally in the oropharynx ahead of time
- Sedate with ketamine and have a paralytic drawn up and ready to push
- Get your view with VL
- If you can get the tube in, go ahead; if not, push the paralytic while keeping your view, then put in the tube
- Sedate

I'm interested in hearing how other places do it.

Hey man, that was very helpful. Thanks!

 

[WilcoWorld]

I've only done it once IRL. It was an obese patient with bad angioedema and poor neck mobility, but 100% O2 sats.

Used the sequence enalli described above, except I did a naso-tracheal approach with a flexible bronchoscope. It was really fun.

3 pointers:

1 - If you have time, dry out the secretions first with a predose of glycopyrrolate. It makes the topical ansethesia more effective.
2 - Be patient, drying & anesthetizing takes a relatively long time to work (though if your dose of ketamine is high enough, this probably matters less).
3 - I only realized after the fact that I should've used a longer tube for a naso-tracheal approach (apparently Anesthesia has these). My standard ETT was essentially hubbed at the nose.

 

[Angry Birds]

I've only done it once IRL. It was an obese patient with bad angioedema and poor neck mobility, but 100% O2 sats.

Used the sequence enalli described above, except I did a naso-tracheal approach with a flexible bronchoscope. It was really fun.

3 pointers:

1 - If you have time, dry out the secretions first with a predose of glycopyrrolate. It makes the topical ansethesia more effective.
2 - Be patient, drying & anesthetizing takes a relatively long time to work (though if your dose of ketamine is high enough, this probably matters less).
3 - I only realized after the fact that I should've used a longer tube for a naso-tracheal approach (apparently Anesthesia has these). My standard ETT was essentially hubbed at the nose.

Thanks for your input.

But, my issue is this: I too have only done 2-3 intubations with a flexible bronchoscope. I did them in residency: we were given samples by the company, and we used them on our next airway patients. Here's the thing: we struggled and fumbled around, despite the fact that these were easy airway patients.

When I get that crazy difficult airway in front of me, do I really want to rely on something I've only done 1-3 times in my life? Shouldn't I use the technique I've done a million times before, and can do in my sleep?

I'm not negating what you're saying... Just musing out loud...

Was this patient sitting up when you did this procedure? I guess that would be a huge advantage, along with of course not losing airway muscles.

 

[WilcoWorld]

Thanks for your input.

But, my issue is this: I too have only done 2-3 intubations with a flexible bronchoscope. I did them in residency: we were given samples by the company, and we used them on our next airway patients. Here's the thing: we struggled and fumbled around, despite the fact that these were easy airway patients.

When I get that crazy difficult airway in front of me, do I really want to rely on something I've only done 1-3 times in my life? Shouldn't I use the technique I've done a million times before, and can do in my sleep?

I'm not negating what you're saying... Just musing out loud...

Was this patient sitting up when you did this procedure? I guess that would be a huge advantage, along with of course not losing airway muscles.

Yep - she was sitting up.

Generally, I agree with what you're saying about going with what you're familiar with. In the case I had, her entire mouth was taken up by her tongue, so the only way in was through the nose or the neck.

And as you alluded to, using ketamine was key, as she kept breathing through the whole thing.

 

[2010houston]

Anesthesia here. One good way to mitigate unfamiliarity w the fiber optic is to use a combined FOB / videoscope technique. Topicalize very well, introduce VL and get a decent / good view of glottis if possible (or as good as you can get), and then have someone else hold videoscope in position while you go in with FOB w loaded tube. Minimizes some of the “getting lost in soft tissue” issues in some cases.

 

[Modanq]

I would consider: Airway blocks tonsillar pillar if you can see it, transtracheal and superior laryngeal + Topicalization. Nasal fiberoptic.
Im an anesthesiology resident x ~ 8/8 (prob all luck) or so attempts in 3 years of residency for angioedema.
In order to confidently (read: internally freaking out) intubate such patients you need to practice with FOI. Most anesthesia residents practice FOI in ENT airway tumors, vocal cord masses, OMFS oropharynx cancer cases, Thoracic surgery mediastinal masses, etc or with Neurosurg/Ortho unstable cervical necks when we need a neuroexam after intubating. When I first started using AFOI it was a steep learning curve ~ 30 or 40 to get the hang of it. Different approaches from the head of the bed or in front of the patient. Nailing the blocks, getting all the meds on board Ketamine, Glyco, haldol, remembering to hook up axillary O2 to the side port of the bronch, managing the hemodynamics so that they don't stroke out while awake as a tube is shoved down their throat/nose. all while preserving RR and ventilation. Plus if possible have the neck preped for a trach and try to do it in the OR.

In the ED setting all bets are off. Hats off to you to try because anesthesia and more often ENT is not in house.

Do you all have the transtracheal jet kits??
Those are a life savers especially if the edema extends down the anterior neck. Its important to remember you can passively oxygenate (similar to jet or oscillatory ventilation) and don't really need to ventilate to remove CO2 and keep the patient alive until they get a definitely airway.

 

[Modanq]

I want to add to my comment above that Anesthesiologist get a real boner/hard nipples over this airway stuff. Im sure there are a bunch of ways to approach this...Bottom line...Consider ECMO.

 

[CliveStaples]

Have done this twice in the past 6 months. Both cases for patient's with prior neck radiation presenting with stridor and suspected significant laryngeal edema. Temporized with steroids, racemic epinephrine, etc. Sedated with Ketamine. Had fiberoptic setup at bedside but took initial look with C-Mac and had succinylcholine available to administer if unable to pass due to lack of paralysis. Both times thankfully I was able to intubate without needing fiberoptic or paralytic but it felt good to have backup ready.

I will say that both experiences made me really want to hit the skills lab and do more fiberoptic intubations and to elect for a fiberoptic approach on more patients in the ER for my education's sake.

 

[TooMuchResearch]

I would consider: Airway blocks tonsillar pillar if you can see it, transtracheal and superior laryngeal + Topicalization. Nasal fiberoptic.
Im an anesthesiology resident x ~ 8/8 (prob all luck) or so attempts in 3 years of residency for angioedema.
In order to confidently (read: internally freaking out) intubate such patients you need to practice with FOI. Most anesthesia residents practice FOI in ENT airway tumors, vocal cord masses, OMFS oropharynx cancer cases, Thoracic surgery mediastinal masses, etc or with Neurosurg/Ortho unstable cervical necks when we need a neuroexam after intubating. When I first started using AFOI it was a steep learning curve ~ 30 or 40 to get the hang of it. Different approaches from the head of the bed or in front of the patient. Nailing the blocks, getting all the meds on board Ketamine, Glyco, haldol, remembering to hook up axillary O2 to the side port of the bronch, managing the hemodynamics so that they don't stroke out while awake as a tube is shoved down their throat/nose. all while preserving RR and ventilation. Plus if possible have the neck preped for a trach and try to do it in the OR.

In the ED setting all bets are off. Hats off to you to try because anesthesia and more often ENT is not in house.

Do you all have the transtracheal jet kits??
Those are a life savers especially if the edema extends down the anterior neck. Its important to remember you can passively oxygenate (similar to jet or oscillatory ventilation) and don't really need to ventilate to remove CO2 and keep the patient alive until they get a definitely airway.

At the places I work 50+% of my shifts, my airway backup is a CRNA at home. I only have a scope at the big house where I could actually get anesthesia or surgical backup if needed. It's important to have the right resources in the right places... We are getting single use scopes for the smaller places though.

 

[coffeebythelake]

Anesthesia here. One good way to mitigate unfamiliarity w the fiber optic is to use a combined FOB / videoscope technique. Topicalize very well, introduce VL and get a decent / good view of glottis if possible (or as good as you can get), and then have someone else hold videoscope in position while you go in with FOB w loaded tube. Minimizes some of the “getting lost in soft tissue” issues in some cases.

I would be cautious with this technique if you are doing awake intubation due to friable mass that might bleed like hell or an abscess that might erupt into a pool of pus with larynogscopy, video or otherwise

I would also be very cautious doing airway blocks instead of topicalization if patients pathology is infectious and close to site of block. 0.2-0.4 mg glycopyrrolate iv followed by lidocaine nebs is an easy way to prepare the airway.

 

[carbonizedeyesockets]

Scott Weingart posted a good review article on awake intubation. (I believe it was from the anesthesia literature.) I have only done one so far. Glycopyrolate to dry the patient out, followed by nebulized 4% lidocaine. Then used lidocaine with a laryngo-tracheal mucosal atomizer to spray the posterior pharynx and down toward the cords. Small aliquots of ketamine and then gently used the glidescope for the intubation. Went well, but an n=1. However, this case was done more to keep the patient breathing due to severe hypercapnic respiratory failure (CO2 >100 despite BiPAP).

In residency we began using the Flexible Intubation Video Endoscope by Karl Storz. We used it for NPLs initially and then for fiberoptic intubation. However, I never got a chance to use it for intubation.

 

[TooMuchResearch]

So, I'm prepping for the oral boards, and the book is talking about awake intubations. I've certainly read about this before, seen EmCrit videos, etc.-- but, I've gotta be honest: I've never done it, even on difficult airway cases.

My experience has taught me that the first pass is the most important. Each successive attempt is tougher and tougher, as the airway becomes edematous and bloody. So, I do everything I can to succeed on the first pass, and this necessarily includes good RSI.

What are your thoughts? Do you do awake intubations, and if so, how do you do it?

And, for the oral boards, how should I think about this issue? Okuda book says that I will be unsuccessful if I RSI a patient with Ludwig's angina. Will they really ding me on the exam for this?

I know this is more of an awake intubation discussion, but:

For oral boards, is the old four quadrant paper system for tracking everything still useful with the new test or maybe just for key things we tend to forget (tetanus, others?)?

 

[2010houston]

Totally agree w above re: friable masses!

 

[coffeebythelake]

I want to add to my comment above that Anesthesiologist get a real boner/hard nipples over this airway stuff. Im sure there are a bunch of ways to approach this...Bottom line...Consider ECMO.

i hope the ECMO comment here was a joke.

Do you all have the transtracheal jet kits??
Those are a life savers especially if the edema extends down the anterior neck. Its important to remember you can passively oxygenate (similar to jet or oscillatory ventilation) and don't really need to ventilate to remove CO2 and keep the patient alive until they get a definitely airway.

agree that transtracheal jet ventilation is a good temporizing measure.
i was taught in anesthesia residency to do surgical cricothyrotomy and have practiced on cadavers, but i think needle crics are more practical for the anesthesiologist. if you've done a transtracheal block before you know how to do a needle cric. after getting the sats up you can then seldinger technique it to place your surgical cric

 

[anbuitachi]

Totally agree w above re: friable masses!

Dont touch the masses.. if there's a oral mass, do awake Nasal intubation. It's extremely rare to see a mass large enough to be in the way of both oral and nasal and be friable at the same time. Either way it's better than putting in a blade in there since you can easily maneuver the fiberoptic. If you really think this is the case then time to either crich or trach

I would be cautious with this technique if you are doing awake intubation due to friable mass that might bleed like hell or an abscess that might erupt into a pool of pus with larynogscopy, video or otherwise

I would also be very cautious doing airway blocks instead of topicalization if patients pathology is infectious and close to site of block. 0.2-0.4 mg glycopyrrolate iv followed by lidocaine nebs is an easy way to prepare the airway.

Yea i would not do blocks if infectious. I dont even do blocks if theres a cancerous mass in the way. The blocks are just to supplement the topicalization. Very rarely do you really need them.
If you plan on awaking the patient, just use the fiberoptic.

 

[Modanq]

i hope the ECMO comment here was a joke.



agree that transtracheal jet ventilation is a good temporizing measure.
i was taught in anesthesia residency to do surgical cricothyrotomy and have practiced on cadavers, but i think needle crics are more practical for the anesthesiologist. if you've done a transtracheal block before you know how to do a needle cric. after getting the sats up you can then seldinger technique it to place your surgical cric

Def exaggerating re: ECMO. What about airway trauma? Folks in the ED prob frequently encounter GSW rifle or self inflicted hitting the anterior neck/face, tracheal transection, wounds etc. Are you guys thinking AFOI? I remember a case (Prior life as a surgical resident) where the anesthesiologist attempted a FOI and failed miserably. How do you guys approach airway trauma? Last I remember from ATLS a steering wheel to chest - one should think aorta and tracheal injury....

 

[Groove]

So, I'm prepping for the oral boards, and the book is talking about awake intubations. I've certainly read about this before, seen EmCrit videos, etc.-- but, I've gotta be honest: I've never done it, even on difficult airway cases.

My experience has taught me that the first pass is the most important. Each successive attempt is tougher and tougher, as the airway becomes edematous and bloody. So, I do everything I can to succeed on the first pass, and this necessarily includes good RSI.

What are your thoughts? Do you do awake intubations, and if so, how do you do it?

And, for the oral boards, how should I think about this issue? Okuda book says that I will be unsuccessful if I RSI a patient with Ludwig's angina. Will they really ding me on the exam for this?

Ketofol or 100% ketamine, whiff of fentanyl
4% lido nebs
4% lido with afrin 1:1 (squirt it in the bottle from the hole on the end with an 18g after you empty half of it, shake and squirt up both nares)
Hurricaine spray (pharyngeal)
glyco

I've found that's a pretty good set up for nasotracheal intubation, nasopharyngoscopy, or awake orotracheal (even better if you can double team with a colleague with one of you driving glide, one driving bronch)

I don't do tracheal blocks in those (extremely rare) cases though I probably should have.. I just don't have any experience doing them. And let's be real...most of us don't have the time to set up for something like this...but if you've got the time, it can go pretty smooth. I've even transferred to cric after a failed nasotracheal intubation during an angioedema case last year and even with the pucker factor, it went pretty smooth. That one with with nothing more than ketofol, fentanyl and afrin. We just didn't have any more time to set up.

 

[Groove]

Kind of off topic, but we also bought a Clarus Levitan and a McGrath to go with our Ambubronch and glide. They are super fun and I highly recommend. The fiber optic intubating stylet is awesome. They aren’t very pricey either.

 

[TooMuchResearch]

Def exaggerating re: ECMO. What about airway trauma? Folks in the ED prob frequently encounter GSW rifle or self inflicted hitting the anterior neck/face, tracheal transection, wounds etc. Are you guys thinking AFOI? I remember a case (Prior life as a surgical resident) where the anesthesiologist attempted a FOI and failed miserably. How do you guys approach airway trauma? Last I remember from ATLS a steering wheel to chest - one should think aorta and tracheal injury....

In my experience, it is very easy to intubate people without faces or with holes in the neck + trachea (your cric is already done!). I don't do much trauma these days other than walk in and the occasional too unstable to bypass me to get to the trauma center.

 

[WilcoWorld]

Def exaggerating re: ECMO. What about airway trauma? Folks in the ED prob frequently encounter GSW rifle or self inflicted hitting the anterior neck/face, tracheal transection, wounds etc. Are you guys thinking AFOI? I remember a case (Prior life as a surgical resident) where the anesthesiologist attempted a FOI and failed miserably. How do you guys approach airway trauma? Last I remember from ATLS a steering wheel to chest - one should think aorta and tracheal injury....

An unstable patient with a bloody airway is the LAST patient I'd do awake FOI on. This is a case for RSI with a prepped neck and someone pre-assigned to cric if the sats go below 80%. Use your favorite tool to your best visualization on first pass and then place your ETT over a bougie.

The AOFI is best suited for stable patients with bad airways. The following looks better in a 2x2 table, but here's how I think about airways in the ED:

1 - Unstable patient + complicated airway: RSI + double back up plan + prepped neck (see above).
2 - Unstable patient + straightforward airway: RSI
3 - Stable patient + complicated airway: AOFI if they're really stable and your really worried. Video assisted laryngoscopy + RSI + back up plan if they're not that stable and you're not that worried.
4 - Stable patient + straightforward airway: Why would the ER intubate this patient?

 

[WilcoWorld]

Ketofol or 100% ketamine, whiff of fentanyl
4% lido nebs
4% lido with afrin 1:1 (squirt it in the bottle from the hole on the end with an 18g after you empty half of it, shake and squirt up both nares)
Hurricaine spray (pharyngeal)
glyco

I've found that's a pretty good set up for nasotracheal intubation, nasopharyngoscopy, or awake orotracheal (even better if you can double team with a colleague with one of you driving glide, one driving bronch)

I don't do tracheal blocks in those (extremely rare) cases though I probably should have.. I just don't have any experience doing them. And let's be real...most of us don't have the time to set up for something like this...but if you've got the time, it can go pretty smooth. I've even transferred to cric after a failed nasotracheal intubation during an angioedema case last year and even with the pucker factor, it went pretty smooth. That one with with nothing more than ketofol, fentanyl and afrin. We just didn't have any more time to set up.

Yep. It's really all about deciding what you'll do if things go south, and committing to doing them before you start the procedure. Things can get tense, but if you've already committed, you just take care of it.

 

[Groove]

Thanks for your input.

But, my issue is this: I too have only done 2-3 intubations with a flexible bronchoscope. I did them in residency: we were given samples by the company, and we used them on our next airway patients. Here's the thing: we struggled and fumbled around, despite the fact that these were easy airway patients.

When I get that crazy difficult airway in front of me, do I really want to rely on something I've only done 1-3 times in my life? Shouldn't I use the technique I've done a million times before, and can do in my sleep?

I'm not negating what you're saying... Just musing out loud...

Was this patient sitting up when you did this procedure? I guess that would be a huge advantage, along with of course not losing airway muscles.

Ask resp when their next conference is.... The bronch vendors are always there and the last one I went to, he had a mannequin with simulated lung and I drove it around for a good 15 mins. Also, just go to one of the good airway courses every few years to sharpen up your skills. I can speak for the Difficult Airway course and it was super high yield and lots of fun. I got a lot of ideas just talking with some of the other docs. Very good lecturers with a lot of real world experience. I've heard good things about Levitan's course but have never been. Also, if you've got one in the dept, just break it out sometime to shake off the cobwebs and re-familiarize yourself and staff with the set up. I booted ours up other day for nothing more than to verify ETT placement/depth, just for the fun of it. (Well, in reality he had a lot of bloody secretions, so it was to verify depth and assess for blood in the trachea/bronchus, but mostly just for fun.) I think when the crap hits the fan though, I would def reach for the tools that are most familiar to you.

Another subset of pt's would be the angioedema pt's that are mild and improving after interval obs and that you intend to send home. You could practice nasopharyngoscopy to assess for supraglottic edema. (You can only really do this on slow days....since if the dept is burning on full cylinders, it's difficult to find the time for set up.) Don't forget about the pt's with FB sensation. That's another group you can practice on.

 

[coffeebythelake]

Def exaggerating re: ECMO. What about airway trauma? Folks in the ED prob frequently encounter GSW rifle or self inflicted hitting the anterior neck/face, tracheal transection, wounds etc. Are you guys thinking AFOI? I remember a case (Prior life as a surgical resident) where the anesthesiologist attempted a FOI and failed miserably. How do you guys approach airway trauma? Last I remember from ATLS a steering wheel to chest - one should think aorta and tracheal injury....

You're starting to deviate from the OP's topic

If it is a bloody ***** mess then don't even think about AFOI, you won't see anything. If tracheal is transected, might be not easy / useless to intubate from above. Depending on the point of injury I would plan for a surgical airway.