Unsuccessful with fiberoptic

[loveumms]

Did an interesting case yesterday:

Older lady - thyroidectomy for large goiter (2cm midline shift of trachea). Pt didn't have symptoms when laying flat. Pt has a MP III with smaller mouth opening and short chin. FROM.

Decision to do sedated fiberoptic keeping her breathing spontaneously because if we can't mask or secure the airway, there is NO way the surgeons can do a trach. Luckily there was no tracheal narrowing. Gave some glycol, versed, dex gtt and small boluses of ketamine. Pt tolerated the sedation and fiberoptic beautifully. HOWEVER, I could not for the life or me get the fiberoptic to flex enough to get past her cords (her airway was so anterior). I tried everything - different positioning of the patient and myself, jaw thrust, pulling the tongue out and everything else I could think of. I finally decided to give a small dose of propofol and see if we can mask her. Easy mask so we induced and paralyzed. I DLx1 with grade IV view with serious cricoid pressure. Switched to glidescope and finally got the tube in it after some serious maneuvering.

Have not encountered this degree of anterior airway where the fiberoptic couldn't get the job done - anyone have any tips/tricks?

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[Planktonmd]

When you say you could not flex enough to pass through the cords do you mean you could see the cords but could not advance the scope or you never got a view of the cords?

 

[ProwlerturnGas]

Unable to fiber optically intubate awake because of her anatomy, surgeon cannot do trach very easily, then turn around and put her to sleep to intubate = Balsy

 

[pgg]

Retrograde wire!

Might've tried a nasal ETT - sometimes the tip of the tube will be pointed a little more anteriorly than if you go through the mouth, and that can get the fiberoptic scope started at a better angle.


Classic board question for these huge goiters is postop respiratory distress from tracheomalacia.

 

[loveumms]

Good idea with the nasal - didn't think about that. Usually is a straight shot right down and avoids that steep angle with anterior airways.

I've never done a retrograde wire and it would have been impossible given her goiter and tracheal deviation. Trying to figure out exactly where the trachea was would have been impossible.

Probably was balsy but I had to do something. I was pretty sure we were not going to have problems masking but figured I would try the safest option first (just in case). We had her with perfect amount sedation to keep breathing during initial attempts (which may have hindered us some with the fiberoptic). Gave her just a touch of propofol which made her apenic long enough to let me know I could mask (and I was confident that the little bit I gave would have worn off fast enough if I couldn't mask and she would restart breathing - although this is always a gamble).

Just for the residents sake - some attendings push a whole 20ml of propofol and claim the patient will recover and start breathing relatively shortly if mask ventilation is unsuccessful. Ask one of your flexible attendings to see how long it actually takes for an adult to recover from 200mg of propofol (hint: its a really long time). I always induce in 10-20mg increments. You will be surprised at just how little it actually takes to render a patient unconscious. Most of the time it's much less then an induction dose … then I will continue to give small boluses as needed for intubation and to get the gas on.

 

[pgg]

I've never done a retrograde wire and it would have been impossible given her goiter and tracheal deviation. Trying to figure out exactly where the trachea was would have been impossible.

Sorry, retrograde wire is a running forum joke. I wasn't seriously suggesting it.

 

[loveumms]

When you say you could not flex enough to pass through the cords do you mean you could see the cords but could not advance the scope or you never got a view of the cords?

Had an excellent view of the cords. Couldn't get the scope to flex enough to get into them. After we induced, I actually tried with the glidescope to get a view of the cords (which still was crappy) and then use the fiberoptic behind the glidescope - you could see the fiberoptic flexed all the way and just couldn't get in. Incredibly frustrating.

 

[loveumms]

Sorry, retrograde wire is a running forum joke. I wasn't seriously suggesting it.

I thought to myself - who does that anymore. I've never seen one, never done one and always wondered if it really did any good. It's crazy how our practice changes so much in a few decades.

 

[Mman]

Had an excellent view of the cords. Couldn't get the scope to flex enough to get into them. After we induced, I actually tried with the glidescope to get a view of the cords (which still was crappy) and then use the fiberoptic behind the glidescope - you could see the fiberoptic flexed all the way and just couldn't get in. Incredibly frustrating.

At that point I keep the tube on the fiberoptic and get it close with glidescope view and then reach down and grab either the fiberoptic or tube with some Magill forceps and point it more anterior while having someone else flex the fiberoptic scope until it is lined up.

 

[Noyac]

Good idea with the nasal - didn't think about that. Usually is a straight shot right down and avoids that steep angle with anterior airways.

I've never done a retrograde wire and it would have been impossible given her goiter and tracheal deviation. Trying to figure out exactly where the trachea was would have been impossible.

Yes the nasal is the most direct approach to the cords and may have helped you some.

If you are not sure where the trachea is then it's probably worth your effort to figure it out. I always do a transtracheal injection on awake FOB because I like the topicalization it provides. However, if I'm doing a difficult one that I'm not absolutely sure I will get the tube in then I pass an 16 or 18g angio or whatever IV cath I have into the trachea and leave it there. Through this I can jet ventilate or pass a retrograde wire. But in this case you didn't know exactly where the trachea was, so grab the US and find it. I've never had to do this but it sure seems easy enough.

Bottomline is, if you don't know where the trachea is then find it before you go looking from above. It makes things much easier.

 

[BuzzPhreed]

I thought to myself - who does that anymore. I've never seen one, never done one and always wondered if it really did any good. It's crazy how our practice changes so much in a few decades.

I've done 4-5 of them. Long run for a short slide. Not usually necessary. Only special circumstances.

 

[risnwb]

I think I might try and pop in an lma while patient was still breathing spontaneously, topicalized, and half awake. Maybe an air-q that has the little ski jump that's supposed to displace the tube anteriorly, and use the fiberoptic through that. Could also try a fastrach lma which has the handle that can help direct the device and the tube towards an anterior larynx. Having the support
Of the lma to brace the fiberoptic scope against might also give more leverage.. Just an idea.


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[chmd]

I'd put in lma and so arndt exchange catheter

 

[Lightwand]

Most fiberoptic scopes don't flex equally anteriorly and posteriorly. Ours (Storz) actually flex more posteriorly, so in the rare case that you describe, which I've seen two or three times (I do a LOT of AFOI), flipping the scope so the flex wheel is actually under the control of your fingers, rather than your thumb will get you the extra bend you need to get to the cords. It's not the easiest to maneuver the scope with it flipped, because the muscle memory isn't there, but it's worked every time I've tried it.

 

[periopdoc]

This

 

[periopdoc]

Nasal was my first thought, although Lightwand's suggestion was my second thought.

With good topicalization, you can do an awake Glidescope.

I helped with one of these in 4th year residency, or maybe it was fellowship. I had the attending hold the Glidescope with as much anterior displacement as the patient could comfortably tolerate, and I ran the bronch. It got things lined up enough for the bronch to make the bend.


-pod

 

[IlDestriero]

I thought to myself - who does that anymore. I've never seen one, never done one and always wondered if it really did any good. It's crazy how our practice changes so much in a few decades.

It is still a valuable technique when you can ID the trachea, but pathology north of that interferes with DL, fiber, etc. It is definitely uncommon, but a good skill to have available. We've used it for kids with massive cystic masses.

 

[amyl]

I use the LMA, aintree catheter trick.... First off you can ventilate ok so you buy yourself time to use fiber optic. Also it seems through the LMA things are lined up better. I have also used the video laryngoscope and the fiberoptic together.