How would you approach this airway?

[rsgillmd]

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I was doing OB today, but my attending (Dr. T) asked me to help another attending out with a potential difficult airway for a TAH/BSO.

The patient is a elderly (late 60s I think) female w/PMH of severe arthritis s/p cervical spine instrumentation, hypercholesterolemia, obesity (5'5" 110 kg), moderate to severe GERD, and uterine CA (reason for surgery).

On floor on clonazepam, fentanyl patch, neurontin or lyrica (one of that group), Protonix, and I don't remember what else.

Looking at her, most of her weight is down below (i.e. neck up she doesn't look scary). Full set of teeth, tongue size seems OK, but very limited head extension and mouth opening (pressing tongue down with tongue depressor to spray local showed me MP 2 view, otherwise MP 4).

She reports a history of difficult intubation -- according to her she was told she had a small "throat" opening. I wasn't sure whether to interpret that as a smaller than normal tube was needed or just that her mouth opening was limited (which I knew already).

I talked with Dr. C (attending on the case) to see what her plan was (not wanting to step on toes). She had called for the fiberoptic but hadn't decided whether she wanted to do it awake or asleep. Since she seemed hesitant, I decided to take charge and said we would do an awake oral fiberoptic. My plan B was to do awake nasal fiberoptic. My plan C was to put her to sleep and do LMA fast-trach. Dr. C had already given pt. glyco 0.2 mg, and Versed 2 mg (didn't touch the lady). The patient was agreeable.

After nebulizing 4% lidocaine just outside the OR (while nurses were setting up), and 2 sprays of benzocaine to elicit cough (while looking for neb equipment), I brought her in to the OR. In OR I positioned her in sniffing position, gave 50 mcg fentanyl, and used atomizer to spray 2 more ml of 4% lido on post. pharynx using the ovassapian as a guide.

The fiberoptic intubation was easy. She gave one cough when my scope accidentally touched left side of trachea (as I was negotiating to carina) and one more cough as the size 7 tube passed through. As soon as I saw the tube sitting above the carina, Dr. C pushed the propofol.

Afterwards I wondered to myself if could have done this lady as an asleep fiberoptic and saved her some anxiety. But my concern was I wasn't sure if I would be able to place an appropriate sized oral airway with limited mouth opening to assist with ventilation.

We got the glidescope a couple of months ago. In retrospect I wondered if I should have had it brought down to me from the main OR.

I feel very comfortable with the fiberoptic scope, and had done 5 or 6 awake intubations prior to today (most have been asleep) so I am comfortable with the awake technique also. So I went with what I was most comfortable.

Dr. T was saying she would have done a nasal fiberoptic because it is easier. But I only struggled once on an awake oral fiberoptic (but so did 2 attendings -- thoracic surgeon finally got it). I have never done an awake nasal fiberoptic (only asleep in kids). I wasn't sure how an adult with tolerate a size 7 tube going down her nostril.

Would you guys have done anything differently? Just want to hear opinions, especially with Plankton (I think) commenting that we do too many awake fiberoptics.

 

[rsgillmd]

As an addendum, in retrospect I wondered if I should have had her sitting. I've done all of my awake fiberoptics with the patient in the sniffing position, and never had a problem.

This patient was given 4 LPM O2 via nasal cannula while I did the intubation, and she never desatted.

Only reason I bring it up is because that was the other thing Dr. T said she would have done.

 

[jetproppilot]

You did a good job....which is that you went with what is most comfortable for you.

And it worked.

All these "difficult intubations", with rare exception, get propofol/sux and a Miller 2 in their throat by me since 99% of the time I can slide an Eschmann in.

The minority in which this technique fails start to breathe on their own within a few minutes......I crank the Sevo wide open, deepen them with mask ventilation until I can insert a nasal tube, then guide it in with the scope.

Nice job, though.

 

[bigeyedfish]

Sounds like you rock-starred it to me. The only thing I would maybe add is some 4% lido transtracheal, but that is not absolutely necessary.

Adults tolerate nasal just as well as oral, but you have to do more prep: neo-syn drops, dilate the nares with trumpets with lido jelly, and be generous with the versed.

With the tolerance she likely has I doubt 2mg of versed and 50 of fent touched her. I wonder if this type of patient would do better with precedex for sedation.

Does anyone do superior laryngeal blocks? I have one attending that loves them.

 

[Planktonmd]

I was doing OB today, but my attending (Dr. T) asked me to help another attending out with a potential difficult airway for a TAH/BSO.

The patient is a elderly (late 60s I think) female w/PMH of severe arthritis s/p cervical spine instrumentation, hypercholesterolemia, obesity (5'5" 110 kg), moderate to severe GERD, and uterine CA (reason for surgery).

On floor on clonazepam, fentanyl patch, neurontin or lyrica (one of that group), Protonix, and I don't remember what else.

Looking at her, most of her weight is down below (i.e. neck up she doesn't look scary). Full set of teeth, tongue size seems OK, but very limited head extension and mouth opening (pressing tongue down with tongue depressor to spray local showed me MP 2 view, otherwise MP 4).

She reports a history of difficult intubation -- according to her she was told she had a small "throat" opening. I wasn't sure whether to interpret that as a smaller than normal tube was needed or just that her mouth opening was limited (which I knew already).

I talked with Dr. C (attending on the case) to see what her plan was (not wanting to step on toes). She had called for the fiberoptic but hadn't decided whether she wanted to do it awake or asleep. Since she seemed hesitant, I decided to take charge and said we would do an awake oral fiberoptic. My plan B was to do awake nasal fiberoptic. My plan C was to put her to sleep and do LMA fast-trach. Dr. C had already given pt. glyco 0.2 mg, and Versed 2 mg (didn't touch the lady). The patient was agreeable.

After nebulizing 4% lidocaine just outside the OR (while nurses were setting up), and 2 sprays of benzocaine to elicit cough (while looking for neb equipment), I brought her in to the OR. In OR I positioned her in sniffing position, gave 50 mcg fentanyl, and used atomizer to spray 2 more ml of 4% lido on post. pharynx using the ovassapian as a guide.

The fiberoptic intubation was easy. She gave one cough when my scope accidentally touched left side of trachea (as I was negotiating to carina) and one more cough as the size 7 tube passed through. As soon as I saw the tube sitting above the carina, Dr. C pushed the propofol.

Afterwards I wondered to myself if could have done this lady as an asleep fiberoptic and saved her some anxiety. But my concern was I wasn't sure if I would be able to place an appropriate sized oral airway with limited mouth opening to assist with ventilation.

We got the glidescope a couple of months ago. In retrospect I wondered if I should have had it brought down to me from the main OR.

I feel very comfortable with the fiberoptic scope, and had done 5 or 6 awake intubations prior to today (most have been asleep) so I am comfortable with the awake technique also. So I went with what I was most comfortable.

Dr. T was saying she would have done a nasal fiberoptic because it is easier. But I only struggled once on an awake oral fiberoptic (but so did 2 attendings -- thoracic surgeon finally got it). I have never done an awake nasal fiberoptic (only asleep in kids). I wasn't sure how an adult with tolerate a size 7 tube going down her nostril.

Would you guys have done anything differently? Just want to hear opinions, especially with Plankton (I think) commenting that we do too many awake fiberoptics.

I think you did an excellent job.
One thing though:
Did you guys consider doing the surgery under regional and avoiding messing with the airway?
I know she is anxious and has chronic pain but why not an epidural or CSE?
Even a continuous spinal would have been a good option.
If it's because of her anxiety that regional was not considered you could have been creative with sedation and even use Precedex.

 

[militarymd]

Did you do a DL after you topicalized?

If you can see, then you can forget the fiber.

Also, after you intubate and paralyze...dl again to see what you can see.

 

[snowman8]

I think you did an excellent job.
One thing though:
Did you guys consider doing the surgery under regional and avoiding messing with the airway?
I know she is anxious and has chronic pain but why not an epidural or CSE?
Even a continuous spinal would have been a good option.
If it's because of her anxiety that regional was not considered you could have been creative with sedation and even use Precedex.

I think doing surgery under neuroaxial anesthesia for pt's with a "difficult airway" to avoid managing their airway is a bad idea. What if you have a failed spinal or epidural, or if the pt becomes unstable during the operation. Is in not better to plan for an elective FOI vs an emergent FOI. Also in my experience pt's tolerate awake orals better than nasals as long as you can abolish their gag reflex. Some argue that nasals are easier b/c more of a straight shot. I just find them more uncomfortable for the pt. Just my experience. Also think transtracheal injections are great, as long as you have a cooperative pt. It doesnt matter which technique you use, as long as you are good at it. I have one attending who swears by the blind nasal light wand and uses it on difficult airways as long as he think he can mask the pt. He nails it about 99% of the time.

 

[jetproppilot]

I think doing surgery under neuroaxial anesthesia for pt's with a "difficult airway" to avoid managing their airway is a bad idea.

Thats the absolute right answer for your oral boards.

Thats the absolute wrong answer out here in the trenches where neuraxial techniques are performed by seasoned clinicians whose high spinal rates are extraordinally low.

Like one every 10 years. Maybe.

Why tackle a difficult airway when you know your regional block is gonna work?

Not saying I'd do regional in this case, but I certainly wouldnt avoid a regional because the patient has a bad airway.

In other words, in my book, difficult airway is not a contraindication for regional anesthesia.

Thats just not how its done out here, no matter what the academic professors are teaching you.

I was taught the same thing, Dude.

And its just plain wrong.

 

[snowman8]

Thats the absolute right answer for your oral boards.

Thats the absolute wrong answer out here in the trenches where neuraxial techniques are performed by seasoned clinicians whose high spinal rates are extraordinally low.

Like one every 10 years. Maybe.

Why tackle a difficult airway when you know your regional block is gonna work?

Not saying I'd do regional in this case, but I wouldnt avoid a regional because the patient has a bad airway.

In other words, in my book, difficult airway is not a contraindication for regional anesthesia.

Thats just not how its done out here, no matter what the academic professors are teaching you.

I was taught the same thing, Dude.

And its just plain wrong.

Not necessarily unstable because of a high spinal, but a more likey scenario what if they have some cardiopulmonary event intraop or the surgeon gets into a lot of bleeding and pt becomes hypotensive and unstable

 

[seinfeld]

Dont feel bad about creating anxiety in patients. I learned when i was an intern that every time i avoided doing something (ie a rectal exam, sexual hx, an extra lab draw) in the name of patient comfort over what the best medical care was i put the patient at risk and a couple times it bit me. i feel much worse about a bad outcome from me trying to be nice than a little patient anxiety. Besides thats what man made drugs for. 😛

I generally do my AFOI in the sitting position but to each his/her own. Name of the game is get the tube in.

 

[jetproppilot]

Not necessarily unstable because of a high spinal, but a more likey scenario what if they have some cardiopulmonary event intraop or the surgeon gets into a lot of bleeding and pt becomes hypotensive and unstable

I understand your thinking.

I beieve our academic residency education spends way too much time teaching you that the right thing to do is to prepare for red herrings, and moulding the way you do cases in that fashion.

You do need to know how to handle difficult airways.

But you don't have to prepare every difficult airway for the absolute worst case scenerio.

After you are out in private practice for a while, if you pick a busy, multi-faceted practice for your first job, your airway skills will become very refined. You will be able to tackle difficult airways quickly, efficiently, and with no fanfare.

I've been in the situation you describe. But then again, I've been in practice eleven years, and I can count those scenerios on my fingers. On every one of those (oh, about 8) cases where a regional was done, something went awry, and we had to secure an airway, we secured an airway.

So you are suggesting (not just you, Dude, our education teaches this) that out of the (literally) thousands of regional cases I've done, I should elect to secure an airway on the patients with difficult airways, rather than do regional?

I'm not buying it.

I can handle a difficult airway, even if its rushed.

But I'm not gonna secure an airway on every regional-patient I do that has a difficult airway.

Additionally, why open up a can of worms that 99.999% of the time, don't have to open?

I'd like to stress again that I take a reported difficult airway with a grain of salt.

Laryngoscopy is a very clinician-dependent skill.

I'd say that the majority of clinicians out there are good, but not great at laryngoscopy.

Who's labeled the patient as a difficult airway?

Most likely, and I'm speaking from what my time in this biz has taught me,

you can get the tube in.

 

[Planktonmd]

I have done regional anesthesia countless times on people who had "documented" difficult intubation.
This case is an abdominal hysterectomy, it's a little bit more involved than your every day C Section, but not that much.
Now think about it this way: You have a woman who is having a c section, she tells you that they had trouble intubating her in the past, would you choose to secure her airway awake and not do a regional anesthetic?

 

[ZA_Gasman]

Does anyone do superior laryngeal blocks? I have one attending that loves them.

SLN blocks? Do them always. I don't waste time with Lido nebs, am just not convinced they work. I do transtracheal lidocaine, SLN blocks (but only 0.5ml or I find an unacceptably high incidence of vomiting for some reason - prob taking down glossopharyngeal nerve as well). A few toots with they lidocaine 10% spray to back of throat, a bit of Remicaine jelly on a pus swab in the nostril, a bit of propofol, only enough to take the edge off (20-30mg) and Bob's your uncle. If I'm careful, they never cough. Try not forget the glyco....

 

[rsgillmd]

I think you did an excellent job.
One thing though:
Did you guys consider doing the surgery under regional and avoiding messing with the airway?
I know she is anxious and has chronic pain but why not an epidural or CSE?
Even a continuous spinal would have been a good option.
If it's because of her anxiety that regional was not considered you could have been creative with sedation and even use Precedex.

In retrospect I could have discussed it with the patient. But in the moment of the situation, it didn't occur to me to do a neuraxial block. That's what I like about this list -- I'll remember it for the future.

I've got to play with Precedex some more. My experience with it is limited.

Thanks again for your comments.

 

[rsgillmd]

Did you do a DL after you topicalized?

If you can see, then you can forget the fiber.

Also, after you intubate and paralyze...dl again to see what you can see.

I didn't think of doing a DL after topicalization at all (meaning the thought didn't enter my mind). I suppose if she can tolerate an ovassapian, she can tolerate a laryngoscope blade. I'll consider trying it in the future.

Thanks militarymd for the comment.