Awake trach?

[LineAndBerry]

What would you do? Assuming relatively healthy pt. without known cardiac or pulm issues......

https://www.anesthesiologynews.com/Multimedia/Article/01-23/Airway-on-Demand-Awake-Tracheostomy-After-Preoperative-Endoscopy/69202?sub=64921BFC164AEE3AB6DDA526F05CBAA5EE8B7122EE34AC5CB4F7E7413750C7&enl=true&dgid=X3634341&utm_source=enl&utm_content=1&utm_campaign=20230121&pos=1&utm_medium=image

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[NumTacos]

That looked pretty nasty, probably do the same thing.

 

[coffeebythelake]

Very reasonable plan. I would do some dexmedotomidine and some versed.

 

[Planktonmd]

Good plan.

 

[TAA66]

I’ve done them before. Dex, generous local by the surgeon is sufficient for the dissection phase. No O2 at this point for the bovie. ENT basically exposes everything and gets right down to the point they are ready to enter the airway, and everyone takes a pause. Patient gets preoxygenated, induced, and surgeon goes in; TIVA, cross field ventilate, and enjoy your reading time. Have your MLTs and difficult airway stuff hanging about should you need it. Not that bad in the hands of a good surgeon (like a lot of things I suppose?)

 

[vector2]

I don't like to give awake trachs anything if I can help it, and most of the time if you can reassure them + have an ENT who uses generous, generous local and who doesn't drape the face, they do just fine with nothing.. But if the pt does need something they may get versed 1mg at a time with the flumazenil vial ready on top of the machine.

 

[patriot6]

I’ve done them before. Dex, generous local by the surgeon is sufficient for the dissection phase. No O2 at this point for the bovie. ENT basically exposes everything and gets right down to the point they are ready to enter the airway, and everyone takes a pause. Patient gets preoxygenated, induced, and surgeon goes in; TIVA, cross field ventilate, and enjoy your reading time. Have your MLTs and difficult airway stuff hanging about should you need it. Not that bad in the hands of a good surgeon (like a lot of things I suppose?)

So… an awake trach until the most critical portion, then just unnecessarily burn all bridges right at the end?

 

[Arch Guillotti]

I have done them without giving any sedation at all or a very judicious amount. Read them the riot act before. ENT 100% on board.

 

[deleted875186]

Big airway mass, awake trach sounds best, looks friable so probably wouldn’t attempt an awake intubation.

I don’t like dexmedetonidine for sedation, I think it has very crappy antianxiolytic properties. I prefer midazolam in small doses, and a short acting opioid, with flumazenil and narcan immediately available.

Agree with above, I wouldn’t give prop right at the critical portion of entering the airway, only after cannulating.

 

[abolt18]

We've got an ENT who does a fair number of awake trach's. He'll specify if he wants sedation or not. Sometimes he explicitly asks us to give zero sedation prior to entering the trachea.

But when we do awake trach's, they do aggressive local, dissect down to the trachea, local into rings/muscle and trans-tracheal. I get propofol ready in line, but don't push until they are in the trachea and placing trach into the airway.

They are honestly super smooth, and it makes me wonder why we ever mess around with AFOI for these sorts of cases.

 

[TAA66]

So… an awake trach until the most critical portion, then just unnecessarily burn all bridges right at the end?

You should know where your pathology lies in the trachea before you ever start the case. In these cases, you have a mass eroding into upper tracheal and a skilled surgeon will be dissecting down below the tumor with plans to enter below, and then proceed with the radical neck dissection. Sometimes we’ll do a quick peak with a fish eye ahead of time for some rapidly changing and/or extremely friable tumors, but that just confirms the oh yeah don’t muck with this from above

Also this all happens within the span of about 15 seconds and kinda simultaneously like abolt says. If your tumor is so low that you’re worried entering the trachea when you’re staring directly at it might still be a problem, then you probably messed up with your planning from the get go. What are your concerns, the tumor is encasing and obstructing the entire trachea to the carina? I’m not sure surgery can fix that in this case.

 

[PpfSuxTube]

I’ve done them before.

Ok. Congratulations. Why are you telling us this like youve landed on the moon or something.

Dex,

Is that dex the steroid or dex the sedative? If its the sedative then well then thats not really awake is it? If somone sedates a patient when the surgeon asks for awake trache they are pooched if the airway is lost... if the surgeon is ok with sedative then sure fine but be very clear on that distinction. Awake trache is not dexmedtomine without that.

The rest is good. You do need to see what neck you're getting into to plan your get out of jail strategy. Rare to need it, but good to have...

A lot of awake trache ive seen, maybe 10 to 15 ive actually intubated using afoi easily enough tbh. One just last week. Theyre usually just narrowed at the cords on presentation the 1st time due to tumor very rarely below the cords. And the stridor usually is clinically obvious at around 6mm narrowing so then with most modern medicine systems they end up in a ct scanner with something a #5.5 tube will slide past... just my experience...

Plus i know our ent very well, if he says afoi then its usually ok. 1 or 2 times he said dont touch, and i quickly stepped away. They got hand holding only.

 

[deleted875186]

Ok. Congratulations. Why are you telling us this like youve landed on the moon or something.


Is that dex the steroid or dex the sedative? If its the sedative then well then thats not really awake is it? If somone sedates a patient when the surgeon asks for awake trache they are pooched if the airway is lost... if the surgeon is ok with sedative then sure fine but be very clear on that distinction. Awake trache is not dexmedtomine without that.

The rest is good. You do need to see what neck you're getting into to plan your get out of jail strategy. Rare to need it, but good to have...

A lot of awake trache ive seen, maybe 10 to 15 ive actually intubated using afoi easily enough tbh. One just last week. Theyre usually just narrowed at the cords on presentation the 1st time due to tumor very rarely below the cords. And the stridor usually is clinically obvious at around 6mm narrowing so then with most modern medicine systems they end up in a ct scanner with something a #5.5 tube will slide past... just my experience...

Plus i know our ent very well, if he says afoi then its usually ok. 1 or 2 times he said dont touch, and i quickly stepped away. They got hand holding only.

I would say giving dexmedetonidine and local by surgeon is “awake”. To be technical it’s mild sedation, but honestly dexmedetonidine by itself, unless patient is really sick or in the ICU, just isn’t really a strong medication.

 

[DocVapor]

If its the sedative then well then thats not really awake is it?

Thank you.

I expect to hear "awake fiberoptic with 150mg ketamine" or "awake trach with some versed and fentanyl" from ER or ICU guys.

I didn't expect to hear it this much from Anesthesiologists.

When I say awake whatever, I mean they get nothing beyond local. As soon as you give anything, it's a sedated procedure.

 

[cchoukal]

I would say giving dexmedetonidine and local by surgeon is “awake”. To be technical it’s mild sedation, but honestly dexmedetonidine by itself, unless patient is really sick or in the ICU, just isn’t really a strong medication.

Depends on dose. I've definitely had upper airway obstruction (what you're explicitly trying to avoid in the awake track scenario) at higher doses of dexmedetomidine. This case, as others have stated, is 95% local, 5% anxiolytics. I like midazolam for this.

 

[coffeebythelake]

Since we decided to nitpick terminology.
Anxiolysis is still awake.
Conscious (as in conscious sedation) is still awake.
If you want unsedated then call it unsedated.

 

[GassYous]

Thank you.

I expect to hear "awake fiberoptic with 150mg ketamine" or "awake trach with some versed and fentanyl" from ER or ICU guys.

I didn't expect to hear it this much from Anesthesiologists.

When I say awake whatever, I mean they get nothing beyond local. As soon as you give anything, it's a sedated procedure.

I think what people mean by "awake" is spontaneously breathing. But you don't need to give meds for someone to not be awake (co2 narcosis, brain bleed).

 

[Angus Avagadro]

I don't like to give awake trachs anything if I can help it, and most of the time if you can reassure them + have an ENT who uses generous, generous local and who doesn't drape the face, they do just fine with nothing.. But if the pt does need something they may get versed 1mg at a time with the flumazenil vial ready on top of the machine.

I agree. It can be done under local with minimal distress to the patient, IF... the ENT is skillful with local and trach skills. As a resident, I observed a rigid bronch done by an older ENT under local only, and was amazed how well the patient tolerated the procedure.

 

[LivetoTell]

Since awake FOI is being discussed. Can anyone share what they think their best technique for anesthetizing the airway?

 

[coffeebythelake]

Since awake FOI is being discussed. Can anyone share what they think their best technique for anesthetizing the airway?

Lots of different ways to do it. Personally I like lidocaine lollipop, spray and gargle followed by tranatracheal.

 

[anaesthetic]

Since awake FOI is being discussed. Can anyone share what they think their best technique for anesthetizing the airway?

Glyco + lidocaine 4% nebulizer/T-piece in preop, posterior oropharyngeal lidocaine 4% atomizer x3, lidocaine 5% jelly on an oral airway (or serial nasal trumpet dilations with lidocaine jelly if nasal approach). If no gag on the oral airway, probably adequately topicalized. If still some gag, either topicalize more or add some Benzocaine spray (usually not needed, not a big fan of it).

I like to run a Precedex infusion +/- Versed while topicalizing, but apparently that’s not really an awake technique and I should be embarrassed to call myself an anesthesiologist.

 

[vector2]

I like to run a Precedex infusion +/- Versed while topicalizing, but apparently that’s not really an awake technique and I should be embarrassed to call myself an anesthesiologist.

I think the crux here wrt awake trachs/awake FOIs etc is that many times people in general (not you specifically) either consciously or subconsciously believe that because we've been consulted or because the procedure is being done with anesthesia that there has to be some kind of IV agent administered, regardless of whether patient actually needs it. I think there are some patients who definitely need sedation to make it through the topicalization and airway securing procedure, but I do my best to determine that on a case by case basis rather than, say, make precedex or versed/fent or ketamine or whatever part of my awake trach/AFOI "recipe"

 

[DocVapor]

Guys I'm not trying to be snarky here. Accuracy of terminology is important. Lazy terms lead to the whole MAC=TIVA="Stun with Propofol" debacle that we all endlessly complain about here.

We're physicians and we need to be both accurate and precise. Surgeons can't get away with op notes that don't accurately describe the operation. Pathologists certainly can't get away with lazy description of what they see.

I like the term unsedated mentioned earlier, but again that may not be entirely accurate because as also pointed out earlier, someone can be unsedated but obtunded.

I don't really care what the terms end up being, but you should be able to say "awake fiberoptic" to me and I instantly know what you mean. I shouldn't have to then try and do the same thing to the same patient for his next surgery, only to dig further and find out that no, they had a precedex bolus then infusion, ended up with 2 mg versed, and finally 50 ketamine did the trick.

 

[nimbus]

Since the discussion has turned to sedation for trachs and intubation, thought I’d post this video which was made by the same doctor who made the video that OP posted. Some people need sedation and some don’t.

 

[narcusprince]

So I did a few of these during my mil time. Inhaled lidocaine works well because when the surgeon dissects into the airway and cannulates they tend to cough and sometimes the trach has to be resized. I find midazolam and low dose remi and inhaled lido works well. The cough reflex is moreso dampened by the strategy.

 

[Radetzky]

Since awake FOI is being discussed. Can anyone share what they think their best technique for anesthetizing the airway?

2% lignocaine injected through the inspiratory limb of high flow nasal cannula

 

[PpfSuxTube]

I would say giving dexmedetonidine and local by surgeon is “awake”. To be technical it’s mild sedation, but honestly dexmedetonidine by itself, unless patient is really sick or in the ICU, just isn’t really a strong medication.

Wasnt there an a&a article couple years back that dexmed had basically same upper aw relaxation properties and effects as ppf?

 

[PpfSuxTube]

Guys I'm not trying to be snarky here. Accuracy of terminology is important. Lazy terms lead to the whole MAC=TIVA="Stun with Propofol" debacle that we all endlessly complain about here.

We're physicians and we need to be both accurate and precise. Surgeons can't get away with op notes that don't accurately describe the operation. Pathologists certainly can't get away with lazy description of what they see.

I like the term unsedated mentioned earlier, but again that may not be entirely accurate because as also pointed out earlier, someone can be unsedated but obtunded.

I don't really care what the terms end up being, but you should be able to say "awake fiberoptic" to me and I instantly know what you mean. I shouldn't have to then try and do the same thing to the same patient for his next surgery, only to dig further and find out that no, they had a precedex bolus then infusion, ended up with 2 mg versed, and finally 50 ketamine did the trick.

100%. And i see residents struggle with this frequently. And other staff...

I would prefer if we called it cooperative foi. So some ppl can indeed be unsedated and tolerate it fine, some need lots of sedation to get to ramsey 4.

Thats the key. You want them ramsey 4/5. Whatever it takes to get there is your skill as a physician. Some its handholding, some way more.

But you wil likely fail if the patient is ramsey 3 or less. Unless they actually have a normal enough airway, then youre just doing afoi for show really

 

[Beeftenderloin]

Guys I'm not trying to be snarky here. Accuracy of terminology is important. Lazy terms lead to the whole MAC=TIVA="Stun with Propofol" debacle that we all endlessly complain about here.

We're physicians and we need to be both accurate and precise. Surgeons can't get away with op notes that don't accurately describe the operation. Pathologists certainly can't get away with lazy description of what they see.

I like the term unsedated mentioned earlier, but again that may not be entirely accurate because as also pointed out earlier, someone can be unsedated but obtunded.

I don't really care what the terms end up being, but you should be able to say "awake fiberoptic" to me and I instantly know what you mean. I shouldn't have to then try and do the same thing to the same patient for his next surgery, only to dig further and find out that no, they had a precedex bolus then infusion, ended up with 2 mg versed, and finally 50 ketamine did the trick.

Not sure I necessarily agree here. A surgeon does a laparoscopic appendectomy but that doesn’t mean you instantly know what all they did. Maybe they used a varess needle when everyone else in their group enters the belly using a hasson technique. Maybe one guy uses harmonic while another uses staples and another likes 0 silk ties. One closes with 4-0 Monacryl, another with skin glue and steri-strips. You get the idea. If you want the specific minutiae of how someone did their AFOI, you gotta actually read the anesthesia record/procedure note.

 

[cchoukal]

Wasnt there an a&a article couple years back that dexmed had basically same upper aw relaxation properties and effects as ppf?

Yes. Anesthesiology, 2019. Small study in healthy volunteers using an unvalidated device and metric for obstruction, but yes.

 

[PpfSuxTube]

Yes. Anesthesiology, 2019. Small study in healthy volunteers using an unvalidated device and metric for obstruction, but yes.

Name a validated metric for obstruction?

 

[DocVapor]

Not sure I necessarily agree here. A surgeon does a laparoscopic appendectomy but that doesn’t mean you instantly know what all they did. Maybe they used a varess needle when everyone else in their group enters the belly using a hasson technique. Maybe one guy uses harmonic while another uses staples and another likes 0 silk ties. One closes with 4-0 Monacryl, another with skin glue and steri-strips. You get the idea. If you want the specific minutiae of how someone did their AFOI, you gotta actually read the anesthesia record/procedure note.

Sure for minutiae, but I'm saying it is more akin to a Lap Chole vs Open Chole. Essentially its the surgeon saying he did a lap chole despite having to convert to an open procedure mid case.

Or, say, you're reading an echo that lists aortic stenosis in the final impression without characterizing it as mild/moderate/severe. Yeah the measurements are likely there in the weeds of the report, but there should be something right up front.

 

[nimbus]

If a patient had an “afoi” in the past, I don’t think it’s unreasonable to read the note. To me, when I read “afoi”, it’s more likely they received some sedation than not.

 

[nimbus]

2% lignocaine injected through the inspiratory limb of high flow nasal cannula

And for the mouth?

 

[coffeebythelake]

I think what people mean by "awake" is spontaneously breathing. But you don't need to give meds for someone to not be awake (co2 narcosis, brain bleed).

A patient can be spontaneously breathjng while under general anesthesia. Just becauae they are spontaneously breathing doesn't say anything about their level of consciousness or how "awake" they are. Regarding your examples... You are referring to depressed levels of consciousness in the setting of specific physiologic and pathologic conditions. Likewise a patient can be awake and not oriented. A demented patient for instance.

Again let's use words appropriately.

Awake means awake.

- A patient can be awake and not fully alert or oriented.
- A patient can be awake and have a depressed level of consciousness.
- A patient can be awake and lightly or moderately sedated.
- however a patient CANNOT be awake and unconscious.

 

[narcusprince]

Since the discussion has turned to sedation for trachs and intubation, thought I’d post this video which was made by the same doctor who made the video that OP posted. Some people need sedation and some don’t.

Im glad you posted this. The S3 blade on the glidescope has a lower profile then the mcgrath blade. Topicalized awake/glidescope intubations can be tolerated well. We should be doing these more often for difficult airways.

 

[coffeebythelake]

Im glad you posted this. The S3 blade on the glidescope has a lower profile then the mcgrath blade. Topicalized awake/glidescope intubations can be tolerated well. We should be doing these more often for difficult airways.

Awake DL or VL is surprisingly well tolerated once the airway is topicalized. Done it before..

 

[repititionition]

My favorite trick is to prove (to yourself) how well you’ve topicalized by an awake look with a glide. More than half the time you can just call for the tube and put it in, provided you have the prop ready.

 

[nimbus]

Im glad you posted this. The S3 blade on the glidescope has a lower profile then the mcgrath blade. Topicalized awake/glidescope intubations can be tolerated well. We should be doing these more often for difficult airways.

It’s exceptionally well tolerated by anesthesiologists who want to make a YouTube video. One of my friends showed me a video where he intubated himself with a glidescope when he was a CA-3, but he never posted it online. All weirdos in my book!

 

[IMGASMD]

It’s exceptionally well tolerated by anesthesiologists who want to make a YouTube video. One of my friends showed me a video where he intubated himself with a glidescope when he was a CA-3, but he never posted it online. All weirdos in my book!

Better than that one who does a transtracheal every year for demonstration of AFOI.

 

[narcusprince]

Why is transtracheal lidocaine necessary? I have never done this before and see little benefit and potential harm if not performed correctly. I favor nebulizer lido in preop holding, oral airway in room with sedation, lido through jet applicator through oral airway. No need for trans tracheal lidocaine.

 

[coffeebythelake]

Why is transtracheal lidocaine necessary? I have never done this before and see little benefit and potential harm if not performed correctly. I favor nebulizer lido in preop holding, oral airway in room with sedation, lido through jet applicator through oral airway. No need for trans tracheal lidocaine.

Some patients have poor effort for nebulizer lidocaine to adequate anesthetize below the VC. Transtracheal is a pretty low risk procedure when performed appropriately. It works really well to anesthetize the lower airway. I also use it to practice finding my airway landmarks.

 

[nimbus]

Transtracheal guy….at 1:55

 

[IMGASMD]

Transtracheal guy….at 1:55

Leave it to Mass Gen and Yale….

 

[cchoukal]

Name a validated metric for obstruction?

Touché.