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I’ll offer a bare bones laryngologist approach that’s my go to, especially for for scarier airways where I really need them wide awake. I do a LOT of awake airway procedures in my office (bronch, vocal fold injections, trachea steroid injections, biopsies, tracheal tumor debulks, lasers, etc) and this has become my basic approach for these plus any awake foi where I’m called for help.
Approach is pretty much the same for all:
-Absolutely no sedation.
-patient fully upright, me facing them the whole time.
-Afrin/4% lido for the nose (few sprays)
-Just a bit of 4% sprayed on tongue base/palate
-begin with trans-nasal scope. Visualize glottis and gradually over a couple minutes drip 10cc of 2% directly onto the cords while they are phonating for maximum time. Usually 0.5-1cc per phonation cycle. Short pauses between to allow it to work. Due to position of working channel, do need to toe-in a bit toward the petiole of epiglottis so the juice hits the cords. Usually pop a couple ccs of that direct into trachea as well. After this, remove scope from nose.
-Well lubed ETT both inside and out.
-use a 4x4 and have patient hold their own tongue.
-drive scope trans oral straight into the airway, staying in posterior glottis so minimal cord touching, position just 2-3cm above carina. Slide tube in gently until I can see it, then scope gtfo.
Then I usually turn to you fine folks to start pushing some drugs asap.
Usually there’s no no coughing or gagging at all. Definitely an art to it and I think the key is the phonatory gargling that deeply numbs the larynx. It’s enough to let me instrument and inject/biopsy the folds; gently sliding a small tube past is likely much less stimulating. These doses also keep me well away from toxic lido levels in all but the tiniest of patient.
The other key is standing facing them because the ergonomics of the scope are designed that way. It’s also how I do the 80-100 scopes /wk in my office so it’s what I’m most comfortable with. But I’ve found trying to do it from above/behind I’m always wishing the scope had one extra bend and I struggle, so I just always do it facing and it works beautifully.
There’s definitely a patient whisperer side of it too, getting them psychologically ready for it. Having them hold their tongue also seems to help, though if they can’t for some reason I’ll have an assistant do that because I need two hands to drive well.
I’ve also forgone the whole phonatory gargling if I didn’t have a working channel scope and just used a trans tracheal block. For me that’s a 10cc syringe, 4cc of 4%, and a 1.5” 25G needle. (Yes you can hit the back wall but it’s a tiny needle and that party wall is thick. ) Usually I aspirating as I’m inserting and once I feel the air as soon as I’m in trachea, I advance a mm or two more and then inject fast. Then I give them a couple minutes to let it soak in. Not as good as the drip method, but still effective.
The more awake airway procedures I do the more amazed I am at how well people can tolerate these things. There are stories from the Jackson era of him doing full direct laryngoscopy and rigid bronchoscopy in fully awake patients!
Approach is pretty much the same for all:
-Absolutely no sedation.
-patient fully upright, me facing them the whole time.
-Afrin/4% lido for the nose (few sprays)
-Just a bit of 4% sprayed on tongue base/palate
-begin with trans-nasal scope. Visualize glottis and gradually over a couple minutes drip 10cc of 2% directly onto the cords while they are phonating for maximum time. Usually 0.5-1cc per phonation cycle. Short pauses between to allow it to work. Due to position of working channel, do need to toe-in a bit toward the petiole of epiglottis so the juice hits the cords. Usually pop a couple ccs of that direct into trachea as well. After this, remove scope from nose.
-Well lubed ETT both inside and out.
-use a 4x4 and have patient hold their own tongue.
-drive scope trans oral straight into the airway, staying in posterior glottis so minimal cord touching, position just 2-3cm above carina. Slide tube in gently until I can see it, then scope gtfo.
Then I usually turn to you fine folks to start pushing some drugs asap.
Usually there’s no no coughing or gagging at all. Definitely an art to it and I think the key is the phonatory gargling that deeply numbs the larynx. It’s enough to let me instrument and inject/biopsy the folds; gently sliding a small tube past is likely much less stimulating. These doses also keep me well away from toxic lido levels in all but the tiniest of patient.
The other key is standing facing them because the ergonomics of the scope are designed that way. It’s also how I do the 80-100 scopes /wk in my office so it’s what I’m most comfortable with. But I’ve found trying to do it from above/behind I’m always wishing the scope had one extra bend and I struggle, so I just always do it facing and it works beautifully.
There’s definitely a patient whisperer side of it too, getting them psychologically ready for it. Having them hold their tongue also seems to help, though if they can’t for some reason I’ll have an assistant do that because I need two hands to drive well.
I’ve also forgone the whole phonatory gargling if I didn’t have a working channel scope and just used a trans tracheal block. For me that’s a 10cc syringe, 4cc of 4%, and a 1.5” 25G needle. (Yes you can hit the back wall but it’s a tiny needle and that party wall is thick. ) Usually I aspirating as I’m inserting and once I feel the air as soon as I’m in trachea, I advance a mm or two more and then inject fast. Then I give them a couple minutes to let it soak in. Not as good as the drip method, but still effective.
The more awake airway procedures I do the more amazed I am at how well people can tolerate these things. There are stories from the Jackson era of him doing full direct laryngoscopy and rigid bronchoscopy in fully awake patients!
