Nasal Fiberoptic Intubations

[DrRobert]

Anyone use these for difficult airways? It seems most people are doing oral fiberoptics.

One advantage I've seen with the nasal is that the cords are right there. One disadvantage being the possibility of bleeding which can ruin your view.

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[Arch Guillotti]

Almost never. Usually just put them in for specific cases, MMF, dental etc.

Jet had a good thread a while back about a person on steroids that bled like stink and made life miserable, IIRC.

 

[RxBoy]

Seen it used once during my ER month. Woman brought in with severe angioedema after medication allergy. Oral intubation was impossible because her tongue literally filled her entire oral orrifce. Anesthesia paged. Was still stating above 90's on 02 vent but slowly destating. The anesthesiologist insisted ENT get on board in case of an emergent airway. Once ENT rushed over, anesthesiologist used nasal fiberoptic scope. Took about 2 minutes till vocal cords were visable. Mind you she was gagging the enitire time. Sux. Tube. Breathe sounds. Note in chart. Gone.

 

[huktonfonix]

Seen it used once during my ER month. Woman brought in with severe angioedema after medication allergy. Oral intubation was impossible because her tongue literally filled her entire oral orrifce. Anesthesia paged. Was still stating above 90's on 02 vent but slowly destating. The anesthesiologist insisted ENT get on board in case of an emergent airway. Once ENT rushed over, anesthesiologist used nasal fiberoptic scope. Took about 2 minutes till vocal cords were visable. Mind you she was gagging the enitire time. Sux. Tube. Breathe sounds. Note in chart. Gone.

Wow. thats just cruel.

 

[RxBoy]

Wow. thats just cruel.

Yeah it was kind of cruel but I guess its better than paralyzing her first only to realize he couldn't find the cords. That would of been an airway nightmare. In his defense, he loaded her full of versed before he began.

 

[Licoricestick]

Nasal would be the norm where I work.
Really good topical anaesthesia, minimal sedation.

Similar anaphylaxis story here recently - much the same technique used, however once cords visualised - local to cords (through the port on the scope), tube through, scope out, cuff up, CO2 confirmed, propofol, THEN muscle relaxant. Sux before the tube goes through the cords has got to increase the risk that you loose your view. Of course if that happens you've then got an unsecured airway in someone who is paralysed and going to be extraordinarily difficult if not impossible to ventilate, so meaning you have to cut the neck (through significant oedema!).

Sux to an awake patient is also cruel and may just get you sued. I would never count on midaz in those circumstances because it doesn't cause amnesia in 100% of people.

 

[huktonfonix]

Yeah it was kind of cruel but I guess its better than paralyzing her first only to realize he couldn't find the cords. That would of been an airway nightmare. In his defense, he loaded her full of versed before he began.

I've never given and will likely never give sux to a patient thats not induced. For awake FBO I get the tube in, give some sort of induction agent, then paralytic. Never give paralytics to an awake patient ("defasciculating doses" the possible exception)

 

[Planktonmd]

Nasal would be the norm where I work.
Really good topical anaesthesia, minimal sedation.

Similar anaphylaxis story here recently - much the same technique used, however once cords visualised - local to cords (through the port on the scope), tube through, scope out, cuff up, CO2 confirmed, propofol, THEN muscle relaxant. Sux before the tube goes through the cords has got to increase the risk that you loose your view. Of course if that happens you've then got an unsecured airway in someone who is paralysed and going to be extraordinarily difficult if not impossible to ventilate, so meaning you have to cut the neck (through significant oedema!).

Sux to an awake patient is also cruel and may just get you sued. I would never count on midaz in those circumstances because it doesn't cause amnesia in 100% of people.

For some reason English anesthesiologists always loved nasal intubation even before fiber optic.
I actually think they still do nasal intubation in the ICU way more than we do (correct me if I am wrong).

 

[Licoricestick]

For some reason English anesthesiologists always loved nasal intubation even before fiber optic.
I actually think they still do nasal intubation in the ICU way more than we do (correct me if I am wrong).

Not sure about the poms - but the historical connection may explain things here.

Our ICUs have a distinct preference for oral tubes - bigger diameter tubes, less issues with pressure necrosis from the tube.

 

[Lonestar]

I use nasal fiberoptic intubation. It has the propensity for epistaxis but this route makes it much easier to find the cords.

Topicalize with 4% lidocaine to the nare. Nebulized lidocaine. Afrin. Glyco preop. etc.

Dilate nares with nasal trumpets.

Place the et tube in warm sterile water. place the tube in the nare about 10-12 cm.

advance the fiberoptic scope throught the et tube.

 

[bluewater]

I primarily use oral FO unless there is an indication for nasal- Oral procedures, angioedema, etc.

I like to pretreat with phenlephrine then topicalize the nares with lido jelly on nasal trumpets (gently) or neb lido. Then for me, there are 2 choices- visualize the cords with the scope and directly spray the cords through the injection port on the scope or transtracheal block +/- SLN block. The blocks may not be feasible when the anatomy is difficult to palpate or the structure of the anatomy is altered- in which case I go with option #1.

As far as NMBDs- I do not push them until the tube is through the cords and confirmed and an induction agent is given. I (with an attending) was burned as a CA-1. In this particular instance (floor of the mouth/ tongue CA)- the pt was mildly sedated, nasal FO scope passed, well tolerated. I had the scope in the trachea and the attending induced and gave paralytic before the tube was passed through the cords. We had a difficult time passing the tube around the mass (the scope went easily) and we were nearly burned. Ultimately, I kept the scope in the trachea and had ENT manipulate the mass. We got lucky.

 

[dfk]

I use nasal fiberoptic intubation. It has the propensity for epistaxis but this route makes it much easier to find the cords.

Topicalize with 4% lidocaine to the nare. Nebulized lidocaine. Afrin. Glyco preop. etc.

Dilate nares with nasal trumpets.

Place the et tube in warm sterile water. place the tube in the nare about 10-12 cm.

advance the fiberoptic scope throught the et tube.

is there any specific reason you use sterile water as opposed to saline? i mean, you are passing a clean tube thru dirty nares, so, it can't be a 'sterile' intent, can it?

 

[pgg]

is there any specific reason you use sterile water as opposed to saline? i mean, you are passing a clean tube thru dirty nares, so, it can't be a 'sterile' intent, can it?

You're right, it doesn't matter. The point is to soften the plastic by putting it in something warm. You could use tap water if you wanted to, or just stick the tube in the blanket warmer (though it takes less time to warm up if you put it in water/saline).

If the nare is already lubed/topicalized I don't think just getting the tube wet adds a whole lot, but it can't hurt.

 

[Idiopathic]

for FO where patient needs to stay awake i do primarily nasal just because the procedure is intrinsically less difficult. it is also fairly standard around here to do awake nasals and asleep orals

ill say that my two least favorite procedures in anesthesia are

1) awake oral intubation
2) awake nasal intubation

 

[SleepIsGood]

Done nasal FO twice. We did this when oral looks just didnt allow us to see much.

Why are you guys visualizing the cords and then spraying Lido? Once you visualize the cords arent you sticking the scope ASAP through the cords and then threading the tube in? In that <20 sec period of time is the lido that you are spraying at the cords really going to help? Or does it just make the pt cough? That's what I've seen.

 

[Idiopathic]

yeah i agree with that. as far as im concerned, coughing is normal. i mean im going to be putting a scope on the carina, theres very little topicalization thats going to help there, i mainly want to numb up the posterior oropharynx, etc, but once i see the cords, im advancing, numb or no