Nebulized lidocaine for awake intubation

[jd1572]

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For those that are using nebulized lidocaine for their awake fiberoptic intubations (placing lidocaine in a nebulizer mask, similar to an albuterol neb), what concentration and volume are you using? I've heard of people using 2% and 4% lidocaine. Anyone getting any local toxicity symptoms with 4% lidocaine? Has anyone ever found that they do not need to do a trans-tracheal block to cover the cords and below if they used a lidocaine neb technique?

Also, how much supplementation (lidocaine atomizer, superior laryngeal nerve blocks, sucking on lidocaine jelly, etc.) of the nebulizer have people been needing with this technique?

Just wondering what other people have been doing. From the few times I've tried it, it seems if the patient is not cooperative in taking deep breaths, this technique might not be so helpful.

 

[MTGas2B]

The nebulizer is kind of a waste, I think. The best device I've found is the atomizer. Gets much better coverage, puts out such a fine mist you can stretch 5 ml of 4% lido a long way.

 

[Jeff05]

I usually use a vial of 4% lidocaine (5 mL) in the nebulizer, but you can use whatever.

As far as toxicity, just do the math (5 mg/kg lidocaine is toxic) and you will be fine.

2 of midaz helps when you're being generous with the local.

 

[Noyac]

Personally I think the best supplement to nebulized lido is a general anesthetic. I have had very poor results or maybe I should say much poorer results with neb lido than my usual technique.

Just this past week I had a case were I decided to use neb lido (typically I never use it b/c it sucks) b/c this guy had a tongue abscess and he could not breath around it unless sitting upright sort of like an epiglotitis case. He was drooling and could not swish and swallow the viscous lido (my favorite) much less his own saliva. This airway was bad without a doubt. The ENT says, "I can drain the abscess under local".😕 I said OK you go first. I was pretty sure the local attempt was going to be futile. It was. The neb lido also did nothing for this procedure. So next we packed the nare with 4% lido and I did my favorite block, the trans tracheal and I left the 18g jelco in the trachea in case we lost the airway. I can jet ventilate thru the 18g and buy some time. We talked about an awake trach as well but I was pretty sure I could get my FOB around his swollen tongue and into the trachea so we went that route. The FOB intubation was performed successfully. Then we drained so much pus out of his tongue that it looked like one of those butt pus cases were the **** keeps coming. We all know that local doesn't work for abscesses but at the time it seemed like there was nothing to lose unless I pushed the toxicity limit which was not an issue.

So back to the original question, nebulized Lidocaine has never worked as well as viscous lido for me. I don't get carried away with blocks but I do the trans tracheal everytime.

 

[Planktonmd]

One common mistake that people do when using nebulized lido is that they use a high flow of oxygen similar to what is done for nebulized broncho dilators.
If you use a high flow then most of your medicine will end up in the distal airways and you will not benefit from it.
You need to keep the flow at 3-4 L/M max and allow a good 30 minutes.
The other point is that the nebulized Lido is never enough by itself and you will still need to supplement it with some topical to the oral cavity and I personally always do a transtracheal as well.

 

[Noyac]

One common mistake that people do when using nebulized lido is that they use a high flow of oxygen similar to what is done for nebulized broncho dilators.
If you use a high flow then most of your medicine will end up in the distal airways and you will not benefit from it.
You need to keep the flow at 3-4 L/M max and allow a good 30 minutes.
The other point is that the nebulized Lido is never enough by itself and you will still need to supplement it with some topical to the oral cavity and I personally always do a transtracheal as well.

Thats good to know Plank. But if you need to supplement the neb lido then why do it at all? And how long does it typically last?

 

[Planktonmd]

Thats good to know Plank. But if you need to supplement the neb lido then why do it at all? And how long does it typically last?

I think the nebulized Lido can improve the quality of your topical and airway blocks and It really helps if you like to intubate then ask the patient to follow certain commands before going to sleep.

 

[Noyac]

I think the nebulized Lido can improve the quality of your topical and airway blocks and It really helps if you like to intubate then ask the patient to follow certain commands before going to sleep.

How long does the numbness last?

 

[Planktonmd]

How long does the numbness last?

30 minutes.

 

[Noyac]

30 minutes.

That's longer than I was told and have experienced. I'll have to try it some more and make sure the flows are low.

 

[jd1572]

thanks to everyone who has shared their tips and opinions. I'll have to try them out!