Awake nasal fiber optic tips?

[B-Bone]

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Had a case tonight that made me consider this. Healthy 16 yo M kicked in face during soccer game 4 days ago--->mandibular fracture. Seen by OMFS, plans elective plate/wire next week after swelling has subsided. Comes into ED tonight with fever/pain/swelling. CT shows abscess with marked airway deviation, but no compression. Tracheal lumen still widely patent. Gets decade on in ED and sent to OR. Very little mouth opening due to pain. Totally NPO x days.

Afrin in preop Pre O2, IV induction. Ensure mask ventilation. Sux. Dilate nares with lubed up nasal airways. Introduce 7.0 nasal RAE. DL with McGills.

Mouth opens OK, but airway is really deviated and abscess is actually large mass obstructing view of cords. Can barely see cos behind abscess and can't get ETT and airway in same plane to advance b/w cords under DL. I place FOB down ETT, but now it's a soupy mess and I can't see s#%*. One more try with DL, but still a no go. At that point I topicalize nose, wake him up and topicalize oropharynx as best as I can. Suction/introduce ETT/drive scope through cords (with some difficulty) and slide tube off.

anyway in retrospect I should have probably just done this awake from the start, but every time I've done awake nasal in the past (maybe once or twice) it turns into a bloody s#%*storm and pts wanna murder me. Soooooo... What's your recipe for awake nasal greatness?

 

[urge]

Toxic dose of lidocaine & some versed to increase the seizure threshold.

 

[deleted126335]

Afrin and glyco in preop. (given by me, not the preop nurse) repeat afrin upon entry to OR. Topicalize nose and oropharynx with your favorite technique. successively larger well lubed nasal airways. Softened (warm saline) and well lubed ETT, advanced just far enough to make the turn.F.O. scope through ETT which should be just above glottis. ANy bleeding should hopefully be contained between mucosa and ETT, atleast till you start moving ETT around. Key is taking your time with the topicalization.

 

[joeDO2]

check out this post from emcrit regarding awake intubation....

http://emcrit.org/misc/awake-intub-video/

 

[rsgillmd]

Afrin and glyco in preop. (given by me, not the preop nurse) repeat afrin upon entry to OR. Topicalize nose and oropharynx with your favorite technique. successively larger well lubed nasal airways. Softened (warm saline) and well lubed ETT, advanced just far enough to make the turn.F.O. scope through ETT which should be just above glottis. ANy bleeding should hopefully be contained between mucosa and ETT, atleast till you start moving ETT around. Key is taking your time with the topicalization.

👍 plus some judicious use of sedation/anxiolysis

 

[Mr Wizard]

Afrin and glyco in preop. (given by me, not the preop nurse) repeat afrin upon entry to OR. Topicalize nose and oropharynx with your favorite technique. successively larger well lubed nasal airways. Softened (warm saline) and well lubed ETT, advanced just far enough to make the turn.F.O. scope through ETT which should be just above glottis. ANy bleeding should hopefully be contained between mucosa and ETT, atleast till you start moving ETT around. Key is taking your time with the topicalization.

I second taking as much time as possible for topicalization, warm saline for the ETT in the above. I use 2-3 cotton swabs or pledgets soaked in 4% lido after the patient has nebulized some as well to get the sphenopalatine and ant. ethmoidals. Do both nares just in case you have trouble with one side.

Dexmedetomidine is a key addition to awake fibers, especially if you are lacking a bit in adequate topical anesthesia. Just starting the infusion while you are working on the anesthesia works well. 1/2 bolus IV if you are pressed for time.

 

[cincincyreds]

I use cocaine for these type of cases. I dab it on cotton pledgets as long as the patient doesnt have cardiac disease. I would also add u need to take time to lot the topical lidocaine work. I've kicked surgeons out of my room in the past when they rush me on these cases.

 

[Ignatius J]

Just curiously, why do you want to do awake versus asleep? All roads lead to Rome, but I don't see the advantage in doing it awake esp. if you have already proven a breath in BMVing the patient.

 

[proman]

I give 50mg of Benadryl in preop before doing anything. Titrate a bit of midazolam while I start topicalizing the nose with a cotton tipped applicator and lido 4%. I liberally apply the lido before using trumpets to apply more. When the biggest trumpet is in, I like to put a MAD atomizer through it and squirt the hypopharynx. Last dilation is the ET tubes. I also keep them upright, easier to handle secretions and easier to do the fiberoptic intubation.

 

[deleted126335]

Just curiously, why do you want to do awake versus asleep? All roads lead to Rome, but I don't see the advantage in doing it awake esp. if you have already proven a breath in BMVing the patient.

Abcesses in the face/airway are tricky.

1. In these cases, I used to assume that limited patient mouth opening on otherwise healthy people with otherwise normal anatomy was secondary to pain. I have found this is not a reliable assumption. (learned the hard way)

2. Put a Mac blade once in the mouth after pushing drugs (had the fiberoptic cart in the room tube loaded and ready to go). A river of pus began flowing.

I do almost all of these cases with an awake fiberoptic technique.

 

[Mman]

Just curiously, why do you want to do awake versus asleep? All roads lead to Rome, but I don't see the advantage in doing it awake esp. if you have already proven a breath in BMVing the patient.

Awake FOI is always easier than asleep, as long as you can get the patient adequately topicalized and anxiolyzed (is that at word?). You can keep them sitting upright and they maintain their muscle tone in the pharnyx. Asleep with a supine patient leads to a lot less space to navigate through in their posterior pharnyx.

 

[Oggg]

I love dumbed down ER videos (sarcasm). I bet they have a "cracking the chest made ridiculously easy" video.

They forgot to mention that for video assisted bougies, you have to add a curve to the distal 6 inches that roughly matches the laryngoscope curve. I can see a bunch of ED docs giving ketofol and then not being able to get a non curved bougie into the trachea.

 

[HollywdAnesth]

My favorite technique is to give glycopyrrolate and afrin. Follow that with a lidocaine neb instructing the patient to only breathe through his/her nose.

I drop an epidural catheter down the suction port and take the injecting end such that the tip is just peeking out of the scope. Once I get a view of the cords, I drive the camera to the anterior portion, and drip lidocaine through the epidural catheter. I've found that this is alot more comfortable for the patient, as an immediate blast can cause the patient to buck and cough jeopardizing your view. That being said, if you're having problems driving to the anterior portion of the cords, you can blast through the catheter as well.

Once the camera is through the cords, I slam in a hefty dose of propofol.

 

[dewer]

noooooooo iv anesthetics in challenging airway

 

[HollywdAnesth]

noooooooo iv anesthetics in challenging airway

Even ketamine or dexmed? I don't agree with that.

We went through truckloads of ketamine in the burn hospital I rotated through.

 

[dewer]

nice techniqe

 

[joeDO2]

I love dumbed down ER videos (sarcasm). I bet they have a "cracking the chest made ridiculously easy" video.

🙁
what would you recommend for someone in EM to become an expert in airway management? Obviously you will get better with pure number but I'm wondering if there is anything else that could be done in the way of training. Airway is such a critical part of EM yet frequently anesthesia comments on how they are not great intubators. Although I plan on going into EM, I'd like to become as proficient with this as possible. I'm headed off to the levitan airway course on wednesday and plan on doing an anesthesia rotation (although this thought is a bit scary after reading the other thread about how annoying med students are!!). Any advice from the experts here would be appreciated!

 

[sevoflurane]

I give 50mg of Benadryl in preop before doing anything. Titrate a bit of midazolam while I start topicalizing the nose with a cotton tipped applicator and lido 4%. I liberally apply the lido before using trumpets to apply more. When the biggest trumpet is in, I like to put a MAD atomizer through it and squirt the hypopharynx. Last dilation is the ET tubes. I also keep them upright, easier to handle secretions and easier to do the fiberoptic intubation.

Exactly what I do. Atomizer does wonders through the nasal trumpet. In the right patient I'll add a transtracheal squirt of LA.. Cotton tipped applicator to the nares knocks out the sphenopalantine ganglion.

 

[cchoukal]

I do a fair number of these (my shop does lots of TMJ and big OMFS stuff on obese people), and here's what I do:

1) psychoprophylaxis: I don't call this "awake" intubation, I tell the patients they'll be partially asleep, but not all the way. I ask 90% of these patients after-the-fact what they recall, and none of them recall anything after going into the OR, so I tell patients up front that they're unlikely to remember any of it.

2) As other have pointed out, vigorous topicalization. I think 90% of the intubation here is in the topical. I start with phenylephrine to the nares, and progressively dilate with nasopharyngeal airways coated in 5% lido ointment. Lots of time taken here. I like to then spray the hypopharynx with 4% lido solution or have them gargle.

3) As far as sedation goes, I start with midazolam 1-4 mg in divided doses in pre-op, and do the bulk of my topicalization in pre-op, as well.

4) to the OR we go. Patient stays seated in the gurney (60 degrees or so). Monitors, more midaz, maybe some fentanyl.

5) I finish with a transtracheal (cricothyroid membrane) with 2 mL 4% lido solution. I find when I do this, once the tube is in, there is no coughing, bucking, or straining. Patients are often comfortable enough to move themselves over to the OR bed once the tube is in.

6) Like someone else above said, I like to insert the ETT into the naris and advance a good way before inserting the scope. I've tried it the other way, loading the tube on the scope and going in scope-first, but I found, particularly with the longer nasal RAE tubes, that the tip of the tube would get to the naris opening before the tip of the scope was in the larynx. This means you're navigating the tip of the scope at the same time that you're trying to shove the ETT into the naris, which is hard to do. The risk of going tube-first is, of course, stirring up bleeding. The phenylephrine should reduce this somewhat, and I haven't encountered lots of problems here.

7) The last thing I'd say is with regard to the Nasal RAE tube. You'll be tempted to use as narrow a tube as possible, but (and this is probably common knowledge, but bears a reminder) the tube size also reflects the length of the tube from the pre-formed bend, so a narrow tube will also be shorter, which can increase the likelihood of ETT dislodgement once the surgeons start moving the neck/head around.

 

[fakin' the funk]

I give 50mg of Benadryl in preop before doing anything.

Brilliant.

 

[proman]

Exactly what I do. Atomizer does wonders through the nasal trumpet. In the right patient I'll add a transtracheal squirt of LA.. Cotton tipped applicator to the nares knocks out the sphenopalantine ganglion.

I'll do that too, but not consistently. Be sure to let the cotton-tipped applicator sit against the sphenoid to get the SP block.

Brilliant.

Benadryl goes a long way but needs time. No need for glyco to dry things out.

Who here thinks that using progressively larger trumpets accomplishes anything? I've been really disappointed with that approach (get the biggest size in and then the ETT doesn't fit).

Oh, one more pearl: make sure you have the correct tube, even in an emergency. I had to switch out a nasal tube after an overnight intubation used a 7.0 ORAL RAE tube in the nose. It wasn't easy.

 

[deleted9493]

I'll do that too, but not consistently. Be sure to let the cotton-tipped applicator sit against the sphenoid to get the SP block.



Benadryl goes a long way but needs time. No need for glyco to dry things out.

Who here thinks that using progressively larger trumpets accomplishes anything? I've been really disappointed with that approach (get the biggest size in and then the ETT doesn't fit).

Oh, one more pearl: make sure you have the correct tube, even in an emergency. I had to switch out a nasal tube after an overnight intubation used a 7.0 ORAL RAE tube in the nose. It wasn't easy.

The notion of progressive dilatation of nasal passages has the scent of myth. The most notable value that I have found in using progressive trumpets is being able to gauge the capacity of the nasal passage and ensure topicalization in the process. I'm sure there are stories of needing to down-size the tube a full mm from the size of the maximum nasal trumpet but it's probably not common. As others have pointed out, your concern in those uncommon circumstances may be of angle to to tip length, calling for a standard microlaryngeal tube or the like.

 

[Mman]

I definitely like one good size nasal trumpet to dilate the nares and help "smooth out" the passage for the ETT. Sometimes takes some twists and turns to get it to pass all the way, but after it does I think it makes a nice track for the softened ETT (warm saline) to slide back to the posterior pharynx before driving the scope through it.

Just make sure not to place it too deep or the scope ends up coming out directly into the posterior wall of the pharynx.

 

[RxBoy]

Once the camera is through the cords, I slam in a hefty dose of propofol.

Got burned with this once. Difficult airway. Pt bucking, coughing, couldn't sit still... I get through the cords, attending slams with propofol. 7.0 tube wouldn't pass past subglottic stenosis. THank god repeat intubation with 6.0 quick but have to admit my heart was pounding after that one.

Another tip I picked up from our FO guru. The second you anticipate an AFOB, hit them with a heavier dose of robinol (0.4 mg) and WAIT 30 minutes before you nebulize. The lido neubilization works so much better because it is actually absorbed by the mucosa and not by the saliva. This plus 4% though the scope and the pt is usually tolerated very well.

Also parker-flex tip tubes make a huge difference in passage.

I've done very little nasal AFOB, but appreciate the tips.

 

[RxBoy]

 

[proman]

I've found the hardest part of the tube to pass through the nose isn't the tip but the cuff. We have these Gore-tex tubes that are nice and soft. Good for elective cases but not what I'd put in an ICU patient.

 

[MErc44]

I think the trans tracheal block is very helpful. In my experience no matter how much nebulizer you use there is some coughing when the ett passes or abuts the vocal cords.

 

[NotAMD]

my recipe is: neo nasal spray, preop dex at 1 mcg/kg/hr x 30-40mins, lido neb., glyco 0.4, midaz 2, fent 50-100, progressive dilation with lido jelly coated nasal trumpets, the last nasal trumpet (usually size 34ish) is cut longitudinally for removal over the scope. just before scope insertion a little ketamine iv (20-30) - this usually makes them somewhat unconscious, sometimes still talking and definitely still breathing - minimal secretion probs

warm, wet, lubed 6.5/7.0 ett is rubber banded to the scope (sometimes i use the tube from the fastrack LMA since it is a little more flexible/rugged). scope through the nasal trumpet, into the chords, nasal trumpet out over the cut, tube into the chords though this step is not always easy, propofol, tape, done

 

[deleted126335]

Use these (Rx Boy's Parker tubes) for all of my oral fiberoptic intubations. I have been a little gunshy about putting it through the nose given the shape of the tip and my concern that it may be more likely to cause bleeding.

 

[sevoflurane]

I know it goes w/o saying... but if there r no contraindications, use cocaine cotton tipped applicators as it will cause vasoconstriction of vascular beds and decrease bleeding. All other local anesthetic are actually vasodilators.

 

[bigdan]

Funk, RxBoy, and other residents -

How many AFOI have you guys done in residency? I've done alarmingly few, and I blame it on the GlideScope.

 

[dhb]

Funk, RxBoy, and other residents -

How many AFOI have you guys done in residency? I've done alarmingly few, and I blame it on the GlideScope.

2 i think...

 

[RxBoy]

Funk, RxBoy, and other residents -

How many AFOI have you guys done in residency? I've done alarmingly few, and I blame it on the GlideScope.

Nasal AFOI: 2 exactly

Oral AFOI: Probably a dozen or so. (one of my attendings push for them in CRNA cases and just have us do the intubation).

Asleep FOB: Probably 50 or so but mainly cause I push for them whenever I can. We also had a fiberoptic sheath study going (see how fast the researcher can turn over FOB scope sheaths) which was a huge plus so I was basically doing 1-2/day for a month. Did a bunch of nasal FOB for teeth extraction during peds too.

I found the trick with laid back attendings is to just have it setup up beforehand and when you are ready to induce just ask, do you mind if I take a shot with the FOB. Usually they don't care because its zero work on their part. Plus we have cordless battery ones so there is minimal setup but at the expense of not having a nice monitor to view.

With that said, their are CA3;s in my class that probably did 10ish.

At any rate, I think I would still be terrified to do one alone on a unstable patient.

 

[RxBoy]

Forgot to mention that I am def lacking the really abnormal glottis airways. Only had 2 cases where there were masses obstructing the view. Our ENT attendings never let anesthesia do the awake FOBI for the really f*ed up airways. Not sure if these site specific, or like that at most hospitals.

 

[proman]

Forgot to mention that I am def lacking the really abnormal glottis airways. Only had 2 cases where there were masses obstructing the view. Our ENT attendings never let anesthesia do the awake FOBI for the really f*ed up airways. Not sure if these site specific, or like that at most hospitals.

I wouldn't worry too much. The hard part is learning how to drive the scope. If you can do it asleep, you can do it awake. Just learn what works when topicalizing and how to give sedation. I think awake, seated, nasal is much easier than asleep, supine, oral.

 

[fakin' the funk]

Funk, RxBoy, and other residents -

How many AFOI have you guys done in residency? I've done alarmingly few, and I blame it on the GlideScope.

Awake nasals - 1 or 2
Awake orals - 15-20. After about the 7th I felt I had "my" topicalization technique down.

The GlideScope thing -- that I don't get.

The GlideScope is an alternative laryngoscope for someone anticipated to be difficult to DL...whereas AFOI is a technique for someone anticipated to be difficult (or inappropriate) to mask-ventilate. (I also think the GlideScope as a "low-pressure-on-the-C-spine-in-an-unstable-C-spine" line of thinking is a bit bogus.)

I don't see these as alternatives to each other.

 

[Mman]

Awake nasals - 1 or 2
Awake orals - 15-20. After about the 7th I felt I had "my" topicalization technique down.

The GlideScope thing -- that I don't get.

The GlideScope is an alternative laryngoscope for someone anticipated to be difficult to DL...whereas AFOI is a technique for someone anticipated to be difficult (or inappropriate) to mask-ventilate. (I also think the GlideScope as a "low-pressure-on-the-C-spine-in-an-unstable-C-spine" line of thinking is a bit bogus.)

I don't see these as alternatives to each other.

You might not see the difference, but if you compare a place with glidescopes (or argue in favor of c-track or whatever your fav is) and a place without, the number of AFOIs will be significantly different between them. Like a lot different. Not even close. Speaking with my older colleagues, they don't do nearly as many AFOIs as they used to before we got a bunch of glidescopes. Don't need to. There are lots of patients with relatively bad looking airways that can open their mouth wide enough to get a glidescope in and it's almost never a problem to intubate them. If you didn't have the glide, in many of those you'd never even try to get them asleep first.

 

[AnesGuy918]

I agree with all the above methods for topicalization of the airways. Especially with use of glyco. I find that small doses of ketamine work well in the AFOI setting.

 

[JSBMD]

Have done a bunch of these in 15 years private practice. Agree with sedation, topicalization (I do trans-tracheal blocks), etc. My addition to this is a practical one, particularly useful for either newbies or those of you who aren't 100% comfortable doing these. While you soften your rae tube in saline, and as you progressively go larger and larger with nasal trumpets in the right side (which happens to be where most of us go), put one of your trumpets in the left nare. To the trumpet in the left nare, insert the connector from your rae tube (which is still in the saline) so that you can then connect the machine circuit to the trumpet in the patient's left nare. The Christmas tree will now hold the circuit for you on the left side while you pursue FOB on the right side. Once intubated, remove the connector from the trumpet and re-insert into the rae tube and away you go. And get rid of the trumpet on the left side, of course.

I hope this makes sense to those of you who have done awake fiberoptic intubations. What usually adds to the stress in the situation is the feeling of pressure time-wise. Also, it is wondering how well the patient is breathing, while the circulator cannot ever seem to resist giving a second-by-second announcement of the O2 saturation. By having the patient breathe via the trumpet and circuit, you will be able to control the FiO2 and to monitor ETCO2, which facilitates your ability to sedate safely.

Good luck

 

[lushmd]

Have done a bunch of these in 15 years private practice. Agree with sedation, topicalization (I do trans-tracheal blocks), etc. My addition to this is a practical one, particularly useful for either newbies or those of you who aren't 100% comfortable doing these. While you soften your rae tube in saline, and as you progressively go larger and larger with nasal trumpets in the right side (which happens to be where most of us go), put one of your trumpets in the left nare. To the trumpet in the left nare, insert the connector from your rae tube (which is still in the saline) so that you can then connect the machine circuit to the trumpet in the patient's left nare. The Christmas tree will now hold the circuit for you on the left side while you pursue FOB on the right side. Once intubated, remove the connector from the trumpet and re-insert into the rae tube and away you go. And get rid of the trumpet on the left side, of course.

I hope this makes sense to those of you who have done awake fiberoptic intubations. What usually adds to the stress in the situation is the feeling of pressure time-wise. Also, it is wondering how well the patient is breathing, while the circulator cannot ever seem to resist giving a second-by-second announcement of the O2 saturation. By having the patient breathe via the trumpet and circuit, you will be able to control the FiO2 and to monitor ETCO2, which facilitates your ability to sedate safely.

Good luck

That's a great tip. At the children's hospital where I did residency, we would often do asleep nasal fiberoptics on kids undergoing dental procedures and do something similar (ventilate via ETT-circuit connector inserted into nasopharyngeal airway with other nare compressed and mouth covered by a tegaderm).

 

[cchoukal]

I use this technique for my obese MAC cases with oral instrumentation (EGD, TEE). Having the somewhat-objective measure of ventilation is priceless. Great tip for the AFOI.

 

[rsgillmd]

Thanks JSBMD. Very nice tip. I will use it next time.

 

[Arch Guillotti]

Once the camera is through the cords, I slam in a hefty dose of propofol.

I think this is a recipe for disaster.

If you can't throw the tube you have a big problem.

I always confirm ETCO2 for several breaths. If your airway anesthesia is adequate tube tolerance is not an issue.

 

[RxBoy]

Question...

Any attendings ever call ENT for an awake FOB they just can't hit? I know its a huge blow to self esteem, but sometimes its whats best for the case. I am wondering when I become an attending if this taboo. WIll ENT even be willing to attempt?

I know we'd like to think we are the experts with all the intubating airway devices. But even if we don't want to admit it, ENT are the experts with the scope. They just do so many more than us.

 

[rsgillmd]

Question...

Any attendings ever call ENT for an awake FOB they just can't hit? I know its a huge blow to self esteem, but sometimes its whats best for the case. I am wondering when I become an attending if this taboo. WIll ENT even be willing to attempt?

I know we'd like to think we are the experts with all the intubating airway devices. But even if we don't want to admit it, ENT are the experts with the scope. They just do so many more than us.

I've done it before to have them on standby in case I run into trouble. I was able to get it.

One time I was getting frustrated and asked the ENT resident if she wanted to take over (drainage of submandibular abscess -- ENT was doing the case anyway). She was apparently less confident in her own skills. I ended up getting it.

I've asked a thoracic surgeon once to help give me his perspective on a difficult case situating a DLT correctly. During residency, I know one of my very experienced attendings did the same thing once.

My point is, don't be afraid to ask for help if you think you need it. Do what is right for the patient. It is only a blow to your self esteem if YOU let it be.

 

[UBCmed09]

My go-to sedation for awakes is titrated remifentanil infusion (usually 0.1 but can start at 0.05). It works beautifully.

 

[Mac4]

I use "epidural catheter" technique instead of trans-tracheal block. If you know how to drive a scope, it is fairly straightforward.

 

[Salt Creep]

IV meds: glyco, 1-2 mg lorazepam IV, 5-10 mg haloperidol IV, and 100 mg hydroxyzine IV. The hydroxyzine is very irritating and must be diluted to 2.5 mg/ml or less and given slowly.

For the heavyweights, add 1-2 mg ketamine at 20 second intervals about one minute before intubation is undertaken.

Topicalization for nasal: mix a slurry of cocaine and 4% lido, work progressively further back with the long Q-tips until you're hitting posterior. Then I leave the Qtip in place and drip the slurry down it.

Have the patient suck on 5% lidocaine (paste) held down by tongue blade on the posterior tongue for several minutes, preferably in the Holding Area.

No amount of sedation can overcome inadequate topicalization.

 

[fakin' the funk]

IV meds: glyco, 1-2 mg lorazepam IV, 5-10 mg haloperidol IV, and 100 mg hydroxyzine IV. The hydroxyzine is very irritating and must be diluted to 2.5 mg/ml or less and given slowly.

For the heavyweights, add 1-2 mg ketamine at 20 second intervals about one minute before intubation is undertaken.

No amount of sedation can overcome inadequate topicalization.

You certainly are trying, though.

 

[Salt Creep]

I'm used to "well-trained" patients.