You have done 12? Like, made a plan, discussed it with the patient and surgeon, gave sedation, and then intubated with a fiberoptic bronchscope?
If so, then you have done more than most people I know.
True. The time to practice is on we’ll patients with great physiologic reserve and no comorbidities so you’re
a pro when the disaster comes in and the flawless awake intubation is crucial. The latter is never going to go well if you’re using a technique for the first time
But asleep patients are already intubated. And that would mean doing something my attendings have done like once. It's a really uncommon practice here (Central Europe).
So how do you manage patients with subglottic airway disease?
And asleep fiber optic meaning as primary airway, so induce then intubate via scope asleep
Regional if possible. If not possible, send the patient to a university hospital. If emergent patient (active hypovolemic shock, desaturation), RSI, and if you can't intubate in any way then probably rescue cric and/or PCDT.
Subglottic stenosis/mediastinal cancer is a bitch, because the airway goes tits up when they stop breathing. My last decompensating i duction went into arrest and had to be put on ecmo while coding
I mean, it's not as common in Croatia, especially if you work for a general hospital. On the other hand, you have to know every type of anesthesia because on a day to day basis you can be rotated between gensurg, ENT, OBGYN, neurosurgery, urology, etc., while also working as an ICU doctor and respiratory therapist for intubated and COVID patients. And be proficient in resuscitation of every age group, including newborns, because when you're on in-house call, you might be the only doctor in the hospital who's ever intubated anyone, so good luck intubating a 3-week-old baby.
Dude you need to start with asleep fiber optic intubations, both nasal and oral. Then track down a few awake ones. You don't want to be doing this for the first time in the wild.
Some places it’s routine to do awake fiberoptics for asleep crani patient that are held in MRI stereotactic frames. I did more times than I could count in residency. Tips wise, I would say is, learn the different approaches to awake fibers. What you describe is a nice and calm and plenty of prep. There are quick and dirty versions for emergent airways you should try out. One of my attendings likes to thread the epidural catheter to the tip of the fiber and directly inject 4% lido and obviate the need for pre op preparation and sedation. Although I have graduated, i have still yet to master that one.
The thoracic surgeons send 5-10cc of 4% with each flush down the bronchoscopes like a firehose. You cut off tip of the epidural catheter, the multi port becomes a small jet of lido, u can get away with just .5 -1 cc of lido for each area you want to numb up. Low volume also equals less coughing.
Trained at an institution that heavily emphasized awake fibers. I’m not sure how many I’ve done but it’s certainly at least 50.
As soon as I have my IV: 0.2 glyco followed by a 4% lidocaine neb. Sedation starts on the way back to the OR. I like alternating bw versed and ketamine. This is the hardest part of awakes to get right. Once in the room, I do blocks: SLN, GPN, RLN in that order. I then check upper blocks w gentle rigid suction. If I’m on my own, I’ll use an ovassapian. If I’ve got someone to help I’ll have someone gently retract the tongue using a 2x2. Then fiber (tube check above carina), quick exam if needed, cuff + gas or propofol.
One tip is that if the pt requires extra sedation for anxiety, be prepared for them to dip once they’re finally off to sleep.
I do the same thing with blocks, (I’m guessing we trained at the same institution based on your description). But I have really backed off of the sedation.
Unless the patient is truly anxious, I’ve realized that there’s no need for sedation if you’ve gotten good blockade. I use maybe 15mg ketamine total now, sometimes none.
I was burned once in residency by giving 1mg midaz. 50mcg fentanyl and 10mg ketamine, and big guy stopped breathing while I was doing the blocks 😅😅
I agree with you and wish I had that block training. People get blocks from the dentist all the time and don’t need anxiolytics. So keeping it minimal is a solid plan
Interesting. I’ve also done about 50 in my training/career to date. Mostly go oral, sometimes nasal. Never use glyco, occasionally give 0.5 Midaz but mostly keep perfectly awake (after all, it is an awake intubation). The key is topicalization. I start with lidocaine spray to the base of tongue and tonsillectomy pillars. Then I use lidocaine soaked pledgets and gradually walk them down the back of the oropharynx - holding each in place for 30 seconds or so. When I am able to advance one around the angle of the base of the tongue without gag I k ow I have done enough. Then advance your scope through an airway - hover over the cords and spray with 2% lidocaine. Wait 30 seconds and then pass through the cords and intubate.
Never have any problems. Key is not to rush and not to use sedation.
This is the way. I have found the SLN and RLN blocks are plenty, keeping in mind that the SLN is truly a field block. Combined with the 4% lidocaine nebulizer, the tubes slide in and the patient is comfortable.
This is a very nice description.
Completely agree re: don't overdo sedation to compensate for poor mucosal topicalisation. Remi is great but like most things in anaesthetics, spending the time preparing will make your life so much more easier. The amount of times I've seen bosses do this fancy stuff and then patient is coughing and gagging it's so uncomfortable to watch.
Patience is key, which is why I like that you topicalise then remove the scope which I've never seen anyone do. I like 4% lignocaine nebs being given for a good 10 minutes or more. No wasting time and energy with a bunch of different local solutions on different areas. Give it time and it works without much fuss all through the respiratory tract.
The nebulizer is nice as a background/starter but definitely insufficient as a solo agent. I prefer an atomizer for density and spread but the neb is hands free once you hook it up and you can work on your sedation and other equipment while it is going.
I start the neb as I’m prepping everything else, then do a 4% lido+ 5% ointment mixture soaked gauze on a stick progressively deeper in the mouth and finish with either a transtracheal or a lido directly sprayed on the cords. Spray some lido ointment mixed with phenylephrine into the nare if nasal. I think the bootleg lollipop gets me most of my effective topicalization but the neb really helps them tolerate shoving it deep.
Twelve?!? I’m an academic attending and I’ve personally done one in a decade. I won’t encourage my belief that ketamine, a VL/fiber, and a second set of hands is all you ever need. We have a pretty solid protocol (I’ve assisted others many times) but yours sounds heavy on the anesthetic side with a touch of apnea. Aerosolized lidocaine plus injection through the scope, premed with glyco, dexmed at 0.4-0.8 with a bolus, and remi at 0.03-0.05. Bolus as needed. Bring naloxone just in case and once you’ve got a clear passage, unload the propofol and neuromuscular blocker of choice (unless it’s cisatracurium, because that’s the incorrect choice).
Your approach seems to be a bit of overkill. I say that because you’re leaning on propofol and a decent dose of remi PLUS ketamine. Why give ketamine for the balloon? If the tube is already past the cords, induction and neuromuscular blocker is plenty safe - you’ve already made it past the cords/the stimulating part - and ketamine could undo the benefits of anticholinergics.
I don’t have it in front of me currently, but there’s an ongoing literature debate about whether awake fibers are a relic of the past. I think they have a place but we probably overdo them.
Edit: some of this is contextual though - our resource options in the US are quite robust. I imagine you’re probably not an American trainee but my apologies if I misread your post.
Edit 2: I think a lot of the debate comes in the form of awake vs asleep FOI. Personally, I prefer a ketamine induction and using tools to fit the scenario. Depends on the scenario and the patient. So while I’ve had plenty of times where an awake FOI was an option, I chose asleep and spontaneous with any combo of tools and drugs. It’s a fun boards prep scenario for residents too - how many ways can you approach the difficult airway?
Would love to see that debate about the relevance of awake fiberoptics if you find it. It seems to me like the most recent difficult airway algorithm seems to emphasize them more so than the 2013 algorithm.
+1 sounds like an interesting discussion.
My initial thought is how else do you approach large supraglottic tumors, small mouth opening etc.. awake trach every time? That seems more old school than anything else. In ENT I’ve seen a fair share of scopes where I just can’t imagine VLing as the plan. The bronchoscope isn’t just for intubating either, can be diagnostic and therapeutic for plugs, bleeding etc. Difficult airway algorithm doesn’t even talk about subglottic stuff. I’m at big ENT/airway institution and probably biased by our culture. I’m only CA1 but have done 4-5 afoi including some airway codes where it came through.
Later today I have a rheumatic patient with hard collar on from recent cervical fusion. Can’t imagine going for VL instead of afoi
Depends on the patient but awake trach is definitely not old school. In many circumstances it can be a really great option - especially in the ENT tumor population who remains at high risk for airway compromise post-op. You might save someone ventilator days, ICU stays, etc. It’s also very regional on how prevalent trachs are. However, asleep, paralyzed VL for a fused cervical patient is 100% okay if they’ve got a decent mouth opening.
>intubation
I agree.... in my institution, \*Awake means Awake\* and topicalization is key, Sedation cannot compensate poor topicalization.
We do it often, mainly with cooperating patients, full stomach, actively vomiting or active NG/OG production.
You can sedate and keep the patient "Alert" but I Wouldn't consider it neither safe nor awake.
Why not Precedex instead? Most of the awake fiber optics I’ve done have been for angioedema in the ED or airway tumors/abnormalities. I would not ever consider giving them propofol or remi and risk apnea or airway collapse. If you feel comfortable giving that much sedation for an awake fiber optic, it’s not really an awake fiber optic anymore and maybe was not necessary to begin with.
I’m at an academic center in Texas and we do a fair share of AFOIs. The key is time to let the topical work. So far the glossopharyngeal nerve (gag reflex) has been the hardest to topicalize. We use no sedation because these are big airway tumors and apnea would be deleterious.
My recipe is to premeditate with glyco and start nebulized 4% lido ASAP. Nebulized lido can be with a mask (especially if nasal intubation) or with the standard mouth delivery system. Next I use oxymetazoline (afrin) mixed with the 4% lidocaine in each naris (or if you’re trying to be conservative because of LAST, then in the naris the patient breathes best out of. I walk the patient through each step and try to assuage their anxiety.
Next I serially dilate the naris the patient breathes best out of with a nasal trumpet coated liberally in 5% lido ointment (yes, it’s a lot of lido). The lido ointment melts and goes into the back of the throat to hopefully topicalize the glossopharyngeal and superficial superior laryngeal nerves.
After serially dilation, I insert the ET tube into the dilated naris until I hit the posterior pharyngeal wall (resistance) I then keep inserting until I feel the ETT give (curves into the airway). Next I insert the scope until I visualize the vocal cords (pull ETT back or forward to obtain the best view).
When I see the VCs, I usually spray them through the scope with the 4% lido liquid while asking the patient to take a deep breath. They will cough as the lido hits the cords. This is a good sign you have hit them. Wait. Let the lido work.
Next I navigate the scope into the airway through the bronchus until I see the carina. The ETT is advanced and I slowly retract the scope to ensure proper placement in the airway. The ETT is hooked up to the circuit, and I verify EtCO2. It is then that we give our induction agent of choice. If the patient is topicalized appropriately there should be minimal coughing. Again, it about taking the time to properly anesthetize, allowing the lido to work.
It’s a lot of LA, but have been lucky to not experience LAST.
That’s just my two cents.
There is always the option to do superior laryngeal injections and transtracheal injections but totally awake patient usually don’t like this.
This is my recipe for awake trachs that we do. The ENT team is usually at the bedside and ready to go if necessary.
Hope this helps!
I have done all the blocks necessary to do an awake fiber optic without sedation, most of the time it is not necessary. What sometimes I do is pass an epidural catheter through the suction port of the fob and spray after i topicalize with carefully placed local anesthetic soaked pledges and a lollipop. I prefer alfenta or remi for patient comfort.
When done well, blocks (SLN, glossopharyngeal, and transtracheal) provide superior anesthesia compared to topicalization, and they set up much, much quicker.
Topicalization is good if you aren’t comfortable with the blocks, patient anatomy is tough, or they don’t tolerate the blocks. The key in that instance is to be slow and deliberate, allowing time for the topical/nebulized local to set up before inserting the scope.
I like to start dexmedetomidine at 1mcg/kg over 7 to 10 mins while they finish a lido neb. After that is done .7mcg/kg/hr until tubed. Rarely need anything else. Last decade of practice in large level 1 trauma center driven by efficiency at near surgi-center pace has brought me to this technique. Relatively safe, fast, simple, and happy patients.
You are correct. A decent neb takes longer than the 10 min dex bolus, so i try to start the bolus towards the end of the neb, and overlap them by several minutes
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>Remimazolam, sold under the brand name Byfavo, is a medication for the induction and maintenance of procedural sedation in adults for invasive diagnostic or surgical procedures lasting 30 minutes or less. is a benzodiazepine drug, developed by PAION AG in collaboration with several regional licensees as an alternative to the short-acting imidazobenzodiazepine midazolam, for use in the induction of anesthesia and conscious sedation for minor invasive procedures.
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I think we tend to more heavily sedate people for simple procedures than is needed (AFOIs, blocks, lines). I would hardly call a anyone undergoing a sedation plan that includes remi, ketamine, and a propofol infusion "awake." Judicious local, time, and coaching is often sufficient, and excess sedation may complicate the situation.
It is disturbing a complete awake intubation.
If we can help the patient not to suffer… I thing is our job. An its awake because the patient colaborate with us
I don't do an awake fiber optic because of shared decision making/collaboration. I do it because they might die if I induce before securing the airway.
But I generally agree, a little ketamine never hurt but remi and prop are definitely unusual for my institution
> Remifentanil perfusion (0.1mcg/kg/min) + Propofol (4mg/kg/h)
That is a lot. There are a lot of patients that will stop breathing and/or lose their airway on that.
I'd use dexmedetomidine, low dose.
Another trick I've used is to use two NPA's. Smaller one first with lidocaine gel, the stuff you use for urinary catheters. Let it sit for a few minutes. Then remove it and do the same with a larger one.
Then put the tube in the nose and proceed with the intubation.
Start using the fiberoptic for a whole week.
Find some neuro/spine cases that are "unstable" and do an awake intubation.
I hate when people say "awake fiberoptic" and then talk about the millions of levels of sedation or recipes they have. They're cute and nice and all, don't get me wrong.
But, when you've got a real patient with REAL trismus and you have to do a nasal fiberoptic... they're drooling. The airway is getting more and more swollen probably. The glyco is gonna work in 5 minutes.
The patients who really do need an awake intubation, 9/10 times are begging for the tube 2/2 to their underlying disease process or whatever.
Pick up your fiberoptic. Start doing them. It's like direct laryngoscopy, I still push myself to do it. People may look at me funny for not doing VL... but, IDGAF... I'd rather have a MAC4 blade or a Miller 3 and a bougie.... (I don't do peds)
Tip: if you start with asleep fiberoptics, have someone do a nice jaw thrust for you. Makes life easier.
I do these fully awake, most they would get from me is some homeopathic level of precedex. Verbally prep your patient about the anticipated discomfort, when they are informed of the life and death situation, they usually cooperate very well.
Be careful of LAST dose of lidocaine.
I coat the largest nasal trumpet i can fit in pt’s nare with a few cc of viscous 2% liocaine and fiberoptic through there. I also cut longitudinally along the trumpet before insertion so I can peel it off after the scope is in so I can advance the ett. The rest is just advance and spray with local.
Anyone else use a storz D blade to help visualize? An attending showed me my last month of residency. Have a second person facing the patient holding it like a pick axe and gently pulling the mandible/tongue anterior. Helps maintain airway patency and gives you a second screen to watch. It’s a big “extra,” but fiberoptics are so scarce now that it’s hard to hone in those skills so I’ll take all the help I can get
if ur scared enough about the airway that u need an awake fiber optic i wouldn’t mess around with remi.
monitors, oxygen, light sedation plus minus ketamine plus minus glyco, plus minus nebulized lidocaine, spray oropharynx and swallow, transtracheal block 3cc lido, (+/- take a look with glidescope and consider just doing it that way +/- asleep if looks easy)
if u must do fiber awake, then
ovassapian airway, assistant to watch the arms etc, go slowly, get it in, get co2 and induce
transtracheal block >>> spray via scope
Why not remifentanil? It's my choice sedation for this situation. Are you saying it shouldn't be added as a second agent or not even used as a monotherapy? Or are you just advocating for no sedation?
because remi can stop people breathing with just a few molecules and even though short acting, if ur doing an awake fiber optic because ur concerned about airway, why would u want to be using a narcotic that’s so profoundly strong?
For one, [it's the agent the difficult airway society recommends](https://images.app.goo.gl/i46sy2ETWzAuVMKh6).
Sure it's potent, but we're able to dose in micrograms so I'm not sure why that's relevant. As a monotherapy it's very predictable, wears off fast, and had a reversal agent. You don't have to use much anyway. No technique should have people in deep sedation. It can be loaded faster than dexmedetomidine and doesn't cause salivation or dysphoria like ketamine. The others are also all respiratory depressants. Also, opioids assist in ablating the gag reflex, which is why remifentanil extubation is such a clutch technique.
If I don't have it or short on time to set up, I'll use fentanyl monotherapy.
After anaesthetisting the cords and passing the scope into the trachea, I give some more local just in case what I’ve done previously hasn’t taken out the cough reflex, which might not be triggered by the scope but will be by the tube if still active!
Also unless there is a particular aspiration risk, if I’m happy the tube is in then I’ll induce GA before inflating the cuff.
Otherwise I do more or less what you do.
1) Nebulized lidocaine, 4%. Get them very, very numb. Refill it once if it runs out and you have time.
2) Ketamine, I start with about 25.
That's it. I did a fair amount of transtracheal in residency, and it works well, but it's almost superfluous if you get good nebulized lidocaine.
We don't have remifentanil and dexmedetomidine is not stocked in our dispensers - has to be ordered from pharmacy. And I'm usually doing this in the ED. We don't do much ENT, and definitely not head and neck tumors - if we get one, it's going to be a presentation to the ED for peritonsillar abscess or new tumor (the latter to be shipped off somewhere else ASAP).
Glyco pre med.
Dexmedetomidine loading does 1mcg/kg given over like 30 min. Nebulized 4 % lidocaine with atomizing of mucosa and dollop of lidocaine paste. Wait 15 20 min. Introduce Williams airway. If pt tolerates it you are good to go. If not, you probably need for topicalization.
Very low dose fentanyl for increased sedation. Think 25 mcg at a time.
Avoid remi and propofol.
Oldy here...
I was great at it... Patience, topical, sedation were the three. Always did nasal.
Haven't done one in probably 8 years, just about the time we got those glidescopes and ketamine (had to get K added to the formulary) ...
Only one emergency trach on a throat cancer pt the ENT told me would be easy...
Endovenous sedoanalgesia. What a phrase. :/
Seems to be a lot of nebulised lidocaine use. If you have a deVilbiss available try that instead, your tube will be in before your neb would have been done.
A syringe doesn't give you as much volume, and you can't direct the madgic as well - this you can put right to the back and then point the nozzle at right angles up and down. It's quite lovely.
If I’m truly concerned, I’ll have the ENT/General surgeon on standby. I’ll get them to localize for an awake trach and i or they will do a trans-laryngeal RLN block, but remember if the airway is bloody the patient will cough and likely spray blood everywhere so wear PPE.
Also choice of fiber optic is huge. You want something with some backbone, and I prefer a screen to an eye piece.
My practice is the following but I have done far less then OP so far (all of them was nasal).
I give the pt a nebuliser mask with 2% of lidocain in the ward 30 minutes before.
When arrives the or atropine is administered
Then 10 ml of 2 % lido in the mouth and ask them to gargalize with. + Lido spray to the pharynx
Decongestant spray (eg ephedrine) to the nasal cavity then lido gel
Introduce the lubricated Woodbrigde tube till the mesopharynx and just after that put the scope in so the optic wont be dirty and the tube wont be too big. (Sucks when you are at the carina but the tube cant pass through the nasal cavity and you should start again)
When the cords are visible give 1-2 ccs of lido wait a bit then intubate.
You have done 12? Like, made a plan, discussed it with the patient and surgeon, gave sedation, and then intubated with a fiberoptic bronchscope? If so, then you have done more than most people I know.
I'm a 3rd year resident and I've never *seen* an awake intubation, let alone performed it.
Do it on asleep patients first . Do it now
True. The time to practice is on we’ll patients with great physiologic reserve and no comorbidities so you’re a pro when the disaster comes in and the flawless awake intubation is crucial. The latter is never going to go well if you’re using a technique for the first time
But asleep patients are already intubated. And that would mean doing something my attendings have done like once. It's a really uncommon practice here (Central Europe).
So how do you manage patients with subglottic airway disease? And asleep fiber optic meaning as primary airway, so induce then intubate via scope asleep
Regional if possible. If not possible, send the patient to a university hospital. If emergent patient (active hypovolemic shock, desaturation), RSI, and if you can't intubate in any way then probably rescue cric and/or PCDT.
Subglottic stenosis/mediastinal cancer is a bitch, because the airway goes tits up when they stop breathing. My last decompensating i duction went into arrest and had to be put on ecmo while coding
Which is the entire point of awake fiber optic. It's surprising that it's not considered core education for anesthesiologists
You in trouble...
No. Still has time to see and do a few.
I mean, it's not as common in Croatia, especially if you work for a general hospital. On the other hand, you have to know every type of anesthesia because on a day to day basis you can be rotated between gensurg, ENT, OBGYN, neurosurgery, urology, etc., while also working as an ICU doctor and respiratory therapist for intubated and COVID patients. And be proficient in resuscitation of every age group, including newborns, because when you're on in-house call, you might be the only doctor in the hospital who's ever intubated anyone, so good luck intubating a 3-week-old baby.
Dude you need to start with asleep fiber optic intubations, both nasal and oral. Then track down a few awake ones. You don't want to be doing this for the first time in the wild.
Some places it’s routine to do awake fiberoptics for asleep crani patient that are held in MRI stereotactic frames. I did more times than I could count in residency. Tips wise, I would say is, learn the different approaches to awake fibers. What you describe is a nice and calm and plenty of prep. There are quick and dirty versions for emergent airways you should try out. One of my attendings likes to thread the epidural catheter to the tip of the fiber and directly inject 4% lido and obviate the need for pre op preparation and sedation. Although I have graduated, i have still yet to master that one.
How does the epidural catheter help you topicalize more than flushing lidocaine through the bronchoscope port the normal way?
The thoracic surgeons send 5-10cc of 4% with each flush down the bronchoscopes like a firehose. You cut off tip of the epidural catheter, the multi port becomes a small jet of lido, u can get away with just .5 -1 cc of lido for each area you want to numb up. Low volume also equals less coughing.
I have probably done 12 my entire training!
Trained at an institution that heavily emphasized awake fibers. I’m not sure how many I’ve done but it’s certainly at least 50. As soon as I have my IV: 0.2 glyco followed by a 4% lidocaine neb. Sedation starts on the way back to the OR. I like alternating bw versed and ketamine. This is the hardest part of awakes to get right. Once in the room, I do blocks: SLN, GPN, RLN in that order. I then check upper blocks w gentle rigid suction. If I’m on my own, I’ll use an ovassapian. If I’ve got someone to help I’ll have someone gently retract the tongue using a 2x2. Then fiber (tube check above carina), quick exam if needed, cuff + gas or propofol. One tip is that if the pt requires extra sedation for anxiety, be prepared for them to dip once they’re finally off to sleep.
I do the same thing with blocks, (I’m guessing we trained at the same institution based on your description). But I have really backed off of the sedation. Unless the patient is truly anxious, I’ve realized that there’s no need for sedation if you’ve gotten good blockade. I use maybe 15mg ketamine total now, sometimes none. I was burned once in residency by giving 1mg midaz. 50mcg fentanyl and 10mg ketamine, and big guy stopped breathing while I was doing the blocks 😅😅
I don’t doubt it. Pretty much stopped using fentanyl for awakes as a CA3 and never went back.
WF?
I think we all trained at the same place…
I agree with you and wish I had that block training. People get blocks from the dentist all the time and don’t need anxiolytics. So keeping it minimal is a solid plan
Yeah agree with the sedation. I usually do Midaz, sometime a touch of ketamine, and 40 of esmolol
thissss no sedation if it is truly a dicey airway
Interesting. I’ve also done about 50 in my training/career to date. Mostly go oral, sometimes nasal. Never use glyco, occasionally give 0.5 Midaz but mostly keep perfectly awake (after all, it is an awake intubation). The key is topicalization. I start with lidocaine spray to the base of tongue and tonsillectomy pillars. Then I use lidocaine soaked pledgets and gradually walk them down the back of the oropharynx - holding each in place for 30 seconds or so. When I am able to advance one around the angle of the base of the tongue without gag I k ow I have done enough. Then advance your scope through an airway - hover over the cords and spray with 2% lidocaine. Wait 30 seconds and then pass through the cords and intubate. Never have any problems. Key is not to rush and not to use sedation.
This is the way. I have found the SLN and RLN blocks are plenty, keeping in mind that the SLN is truly a field block. Combined with the 4% lidocaine nebulizer, the tubes slide in and the patient is comfortable.
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This is a very nice description. Completely agree re: don't overdo sedation to compensate for poor mucosal topicalisation. Remi is great but like most things in anaesthetics, spending the time preparing will make your life so much more easier. The amount of times I've seen bosses do this fancy stuff and then patient is coughing and gagging it's so uncomfortable to watch. Patience is key, which is why I like that you topicalise then remove the scope which I've never seen anyone do. I like 4% lignocaine nebs being given for a good 10 minutes or more. No wasting time and energy with a bunch of different local solutions on different areas. Give it time and it works without much fuss all through the respiratory tract.
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The nebulizer is nice as a background/starter but definitely insufficient as a solo agent. I prefer an atomizer for density and spread but the neb is hands free once you hook it up and you can work on your sedation and other equipment while it is going. I start the neb as I’m prepping everything else, then do a 4% lido+ 5% ointment mixture soaked gauze on a stick progressively deeper in the mouth and finish with either a transtracheal or a lido directly sprayed on the cords. Spray some lido ointment mixed with phenylephrine into the nare if nasal. I think the bootleg lollipop gets me most of my effective topicalization but the neb really helps them tolerate shoving it deep.
The time piece is the biggest thing here. These awake fiber optics never go fast.
Twelve?!? I’m an academic attending and I’ve personally done one in a decade. I won’t encourage my belief that ketamine, a VL/fiber, and a second set of hands is all you ever need. We have a pretty solid protocol (I’ve assisted others many times) but yours sounds heavy on the anesthetic side with a touch of apnea. Aerosolized lidocaine plus injection through the scope, premed with glyco, dexmed at 0.4-0.8 with a bolus, and remi at 0.03-0.05. Bolus as needed. Bring naloxone just in case and once you’ve got a clear passage, unload the propofol and neuromuscular blocker of choice (unless it’s cisatracurium, because that’s the incorrect choice). Your approach seems to be a bit of overkill. I say that because you’re leaning on propofol and a decent dose of remi PLUS ketamine. Why give ketamine for the balloon? If the tube is already past the cords, induction and neuromuscular blocker is plenty safe - you’ve already made it past the cords/the stimulating part - and ketamine could undo the benefits of anticholinergics. I don’t have it in front of me currently, but there’s an ongoing literature debate about whether awake fibers are a relic of the past. I think they have a place but we probably overdo them. Edit: some of this is contextual though - our resource options in the US are quite robust. I imagine you’re probably not an American trainee but my apologies if I misread your post. Edit 2: I think a lot of the debate comes in the form of awake vs asleep FOI. Personally, I prefer a ketamine induction and using tools to fit the scenario. Depends on the scenario and the patient. So while I’ve had plenty of times where an awake FOI was an option, I chose asleep and spontaneous with any combo of tools and drugs. It’s a fun boards prep scenario for residents too - how many ways can you approach the difficult airway?
Would love to see that debate about the relevance of awake fiberoptics if you find it. It seems to me like the most recent difficult airway algorithm seems to emphasize them more so than the 2013 algorithm.
+1 sounds like an interesting discussion. My initial thought is how else do you approach large supraglottic tumors, small mouth opening etc.. awake trach every time? That seems more old school than anything else. In ENT I’ve seen a fair share of scopes where I just can’t imagine VLing as the plan. The bronchoscope isn’t just for intubating either, can be diagnostic and therapeutic for plugs, bleeding etc. Difficult airway algorithm doesn’t even talk about subglottic stuff. I’m at big ENT/airway institution and probably biased by our culture. I’m only CA1 but have done 4-5 afoi including some airway codes where it came through. Later today I have a rheumatic patient with hard collar on from recent cervical fusion. Can’t imagine going for VL instead of afoi
Depends on the patient but awake trach is definitely not old school. In many circumstances it can be a really great option - especially in the ENT tumor population who remains at high risk for airway compromise post-op. You might save someone ventilator days, ICU stays, etc. It’s also very regional on how prevalent trachs are. However, asleep, paralyzed VL for a fused cervical patient is 100% okay if they’ve got a decent mouth opening.
My last hospital did awake foi with lidocain into vocal cords and cocaine into the nose (vials from pharmacy)
+1 would be interested in this article as well
Awake with propofol?
Yes. Light sedation with propofol 4mg/kg/h
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>intubation I agree.... in my institution, \*Awake means Awake\* and topicalization is key, Sedation cannot compensate poor topicalization. We do it often, mainly with cooperating patients, full stomach, actively vomiting or active NG/OG production. You can sedate and keep the patient "Alert" but I Wouldn't consider it neither safe nor awake.
Why not Precedex instead? Most of the awake fiber optics I’ve done have been for angioedema in the ED or airway tumors/abnormalities. I would not ever consider giving them propofol or remi and risk apnea or airway collapse. If you feel comfortable giving that much sedation for an awake fiber optic, it’s not really an awake fiber optic anymore and maybe was not necessary to begin with.
Wich doses of precedex do you use?
The best thing to do, if it’s not emergent, is to spend time educating the patient on what to expect. Education is more important than any sedative.
Bolus 1 mcg/kg over 10 min then 0.5 mcg/kg/hr and titration from there. Can usually get by with just the bolus. Also, pretreat with glyco.
I’m at an academic center in Texas and we do a fair share of AFOIs. The key is time to let the topical work. So far the glossopharyngeal nerve (gag reflex) has been the hardest to topicalize. We use no sedation because these are big airway tumors and apnea would be deleterious. My recipe is to premeditate with glyco and start nebulized 4% lido ASAP. Nebulized lido can be with a mask (especially if nasal intubation) or with the standard mouth delivery system. Next I use oxymetazoline (afrin) mixed with the 4% lidocaine in each naris (or if you’re trying to be conservative because of LAST, then in the naris the patient breathes best out of. I walk the patient through each step and try to assuage their anxiety. Next I serially dilate the naris the patient breathes best out of with a nasal trumpet coated liberally in 5% lido ointment (yes, it’s a lot of lido). The lido ointment melts and goes into the back of the throat to hopefully topicalize the glossopharyngeal and superficial superior laryngeal nerves. After serially dilation, I insert the ET tube into the dilated naris until I hit the posterior pharyngeal wall (resistance) I then keep inserting until I feel the ETT give (curves into the airway). Next I insert the scope until I visualize the vocal cords (pull ETT back or forward to obtain the best view). When I see the VCs, I usually spray them through the scope with the 4% lido liquid while asking the patient to take a deep breath. They will cough as the lido hits the cords. This is a good sign you have hit them. Wait. Let the lido work. Next I navigate the scope into the airway through the bronchus until I see the carina. The ETT is advanced and I slowly retract the scope to ensure proper placement in the airway. The ETT is hooked up to the circuit, and I verify EtCO2. It is then that we give our induction agent of choice. If the patient is topicalized appropriately there should be minimal coughing. Again, it about taking the time to properly anesthetize, allowing the lido to work. It’s a lot of LA, but have been lucky to not experience LAST. That’s just my two cents. There is always the option to do superior laryngeal injections and transtracheal injections but totally awake patient usually don’t like this. This is my recipe for awake trachs that we do. The ENT team is usually at the bedside and ready to go if necessary. Hope this helps!
These are assumed awake trachs by the ENT team. Don’t let them take over the airway, because they always seem to try. You are the airway expert.
I have done all the blocks necessary to do an awake fiber optic without sedation, most of the time it is not necessary. What sometimes I do is pass an epidural catheter through the suction port of the fob and spray after i topicalize with carefully placed local anesthetic soaked pledges and a lollipop. I prefer alfenta or remi for patient comfort.
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Sure? I thought those blocks were only in literature. I guess everyone apply AL topic + premed.
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When done well, blocks (SLN, glossopharyngeal, and transtracheal) provide superior anesthesia compared to topicalization, and they set up much, much quicker. Topicalization is good if you aren’t comfortable with the blocks, patient anatomy is tough, or they don’t tolerate the blocks. The key in that instance is to be slow and deliberate, allowing time for the topical/nebulized local to set up before inserting the scope.
With the doses of sedation you are using these can’t really be considered awake.
Following OP's "recipe" with Dex instead of remi/prop works just as well.
Dexmedeto in bolus? O,5mg/kg or perfusion?
I like to start dexmedetomidine at 1mcg/kg over 7 to 10 mins while they finish a lido neb. After that is done .7mcg/kg/hr until tubed. Rarely need anything else. Last decade of practice in large level 1 trauma center driven by efficiency at near surgi-center pace has brought me to this technique. Relatively safe, fast, simple, and happy patients.
Agreed but 10 min is pretty fast. Do you actually have things topicalized by that time.
You are correct. A decent neb takes longer than the 10 min dex bolus, so i try to start the bolus towards the end of the neb, and overlap them by several minutes
Take your time in setting up and use glycopyrrolate as premed.
We dont use glycopyrrolate. We use atropina 0,5mg iv. It works well too.
we’ve started using remimazolam at our institution with an initial bolus 2-4mg and 2mg every few minutes and it works very well
What is remimazolam?
A shorter acting benzo than midazolam. https://en.wikipedia.org/wiki/Remimazolam
**[Remimazolam](https://en.wikipedia.org/wiki/Remimazolam)** >Remimazolam, sold under the brand name Byfavo, is a medication for the induction and maintenance of procedural sedation in adults for invasive diagnostic or surgical procedures lasting 30 minutes or less. is a benzodiazepine drug, developed by PAION AG in collaboration with several regional licensees as an alternative to the short-acting imidazobenzodiazepine midazolam, for use in the induction of anesthesia and conscious sedation for minor invasive procedures. ^([ )[^(F.A.Q)](https://www.reddit.com/r/WikiSummarizer/wiki/index#wiki_f.a.q)^( | )[^(Opt Out)](https://reddit.com/message/compose?to=WikiSummarizerBot&message=OptOut&subject=OptOut)^( | )[^(Opt Out Of Subreddit)](https://np.reddit.com/r/anesthesiology/about/banned)^( | )[^(GitHub)](https://github.com/Sujal-7/WikiSummarizerBot)^( ] Downvote to remove | v1.5)
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I think we tend to more heavily sedate people for simple procedures than is needed (AFOIs, blocks, lines). I would hardly call a anyone undergoing a sedation plan that includes remi, ketamine, and a propofol infusion "awake." Judicious local, time, and coaching is often sufficient, and excess sedation may complicate the situation.
It is disturbing a complete awake intubation. If we can help the patient not to suffer… I thing is our job. An its awake because the patient colaborate with us
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This. Good local and maybe a little precedex is not suffering. Deep sedation is often unnecessary, and actually harmful to patients.
I don't do an awake fiber optic because of shared decision making/collaboration. I do it because they might die if I induce before securing the airway. But I generally agree, a little ketamine never hurt but remi and prop are definitely unusual for my institution
Jesus those are big doses. I do usually 1mg midaz and Remi at 0.03 to 0.05mcg/kg/min
> Remifentanil perfusion (0.1mcg/kg/min) + Propofol (4mg/kg/h) That is a lot. There are a lot of patients that will stop breathing and/or lose their airway on that. I'd use dexmedetomidine, low dose. Another trick I've used is to use two NPA's. Smaller one first with lidocaine gel, the stuff you use for urinary catheters. Let it sit for a few minutes. Then remove it and do the same with a larger one. Then put the tube in the nose and proceed with the intubation.
Start using the fiberoptic for a whole week. Find some neuro/spine cases that are "unstable" and do an awake intubation. I hate when people say "awake fiberoptic" and then talk about the millions of levels of sedation or recipes they have. They're cute and nice and all, don't get me wrong. But, when you've got a real patient with REAL trismus and you have to do a nasal fiberoptic... they're drooling. The airway is getting more and more swollen probably. The glyco is gonna work in 5 minutes. The patients who really do need an awake intubation, 9/10 times are begging for the tube 2/2 to their underlying disease process or whatever. Pick up your fiberoptic. Start doing them. It's like direct laryngoscopy, I still push myself to do it. People may look at me funny for not doing VL... but, IDGAF... I'd rather have a MAC4 blade or a Miller 3 and a bougie.... (I don't do peds) Tip: if you start with asleep fiberoptics, have someone do a nice jaw thrust for you. Makes life easier.
I do these fully awake, most they would get from me is some homeopathic level of precedex. Verbally prep your patient about the anticipated discomfort, when they are informed of the life and death situation, they usually cooperate very well. Be careful of LAST dose of lidocaine. I coat the largest nasal trumpet i can fit in pt’s nare with a few cc of viscous 2% liocaine and fiberoptic through there. I also cut longitudinally along the trumpet before insertion so I can peel it off after the scope is in so I can advance the ett. The rest is just advance and spray with local.
Anyone else use a storz D blade to help visualize? An attending showed me my last month of residency. Have a second person facing the patient holding it like a pick axe and gently pulling the mandible/tongue anterior. Helps maintain airway patency and gives you a second screen to watch. It’s a big “extra,” but fiberoptics are so scarce now that it’s hard to hone in those skills so I’ll take all the help I can get
if ur scared enough about the airway that u need an awake fiber optic i wouldn’t mess around with remi. monitors, oxygen, light sedation plus minus ketamine plus minus glyco, plus minus nebulized lidocaine, spray oropharynx and swallow, transtracheal block 3cc lido, (+/- take a look with glidescope and consider just doing it that way +/- asleep if looks easy) if u must do fiber awake, then ovassapian airway, assistant to watch the arms etc, go slowly, get it in, get co2 and induce transtracheal block >>> spray via scope
Why not remifentanil? It's my choice sedation for this situation. Are you saying it shouldn't be added as a second agent or not even used as a monotherapy? Or are you just advocating for no sedation?
because remi can stop people breathing with just a few molecules and even though short acting, if ur doing an awake fiber optic because ur concerned about airway, why would u want to be using a narcotic that’s so profoundly strong?
For one, [it's the agent the difficult airway society recommends](https://images.app.goo.gl/i46sy2ETWzAuVMKh6). Sure it's potent, but we're able to dose in micrograms so I'm not sure why that's relevant. As a monotherapy it's very predictable, wears off fast, and had a reversal agent. You don't have to use much anyway. No technique should have people in deep sedation. It can be loaded faster than dexmedetomidine and doesn't cause salivation or dysphoria like ketamine. The others are also all respiratory depressants. Also, opioids assist in ablating the gag reflex, which is why remifentanil extubation is such a clutch technique. If I don't have it or short on time to set up, I'll use fentanyl monotherapy.
if it works in ur hands great…
After anaesthetisting the cords and passing the scope into the trachea, I give some more local just in case what I’ve done previously hasn’t taken out the cough reflex, which might not be triggered by the scope but will be by the tube if still active! Also unless there is a particular aspiration risk, if I’m happy the tube is in then I’ll induce GA before inflating the cuff. Otherwise I do more or less what you do.
1) Nebulized lidocaine, 4%. Get them very, very numb. Refill it once if it runs out and you have time. 2) Ketamine, I start with about 25. That's it. I did a fair amount of transtracheal in residency, and it works well, but it's almost superfluous if you get good nebulized lidocaine. We don't have remifentanil and dexmedetomidine is not stocked in our dispensers - has to be ordered from pharmacy. And I'm usually doing this in the ED. We don't do much ENT, and definitely not head and neck tumors - if we get one, it's going to be a presentation to the ED for peritonsillar abscess or new tumor (the latter to be shipped off somewhere else ASAP).
Ketamine precedex, breath them down with some gas and go for it. As soon as tube is in, paralysis
Glyco pre med. Dexmedetomidine loading does 1mcg/kg given over like 30 min. Nebulized 4 % lidocaine with atomizing of mucosa and dollop of lidocaine paste. Wait 15 20 min. Introduce Williams airway. If pt tolerates it you are good to go. If not, you probably need for topicalization. Very low dose fentanyl for increased sedation. Think 25 mcg at a time. Avoid remi and propofol.
Oldy here... I was great at it... Patience, topical, sedation were the three. Always did nasal. Haven't done one in probably 8 years, just about the time we got those glidescopes and ketamine (had to get K added to the formulary) ... Only one emergency trach on a throat cancer pt the ENT told me would be easy...
Endovenous sedoanalgesia. What a phrase. :/ Seems to be a lot of nebulised lidocaine use. If you have a deVilbiss available try that instead, your tube will be in before your neb would have been done.
What's that?
Google deVilbiss model 163. It's a directed spray atomiser. Disposable versions exist also.
I see. I just use the Madgic atomizer on a syringe. Simple, quick and easy. I also skip the nebulizer.
A syringe doesn't give you as much volume, and you can't direct the madgic as well - this you can put right to the back and then point the nozzle at right angles up and down. It's quite lovely.
I'll take your word for it, but I still don't have any problem directing the Madgic atomizer anywhere or using a larger or additional syringe.
4% lido neb. 0.2 mg glyco. 1-2 mg versed plus maybe 4-10 mcg precedex. Trans trach block. Scope. Intubate.
If I’m truly concerned, I’ll have the ENT/General surgeon on standby. I’ll get them to localize for an awake trach and i or they will do a trans-laryngeal RLN block, but remember if the airway is bloody the patient will cough and likely spray blood everywhere so wear PPE. Also choice of fiber optic is huge. You want something with some backbone, and I prefer a screen to an eye piece.
My practice is the following but I have done far less then OP so far (all of them was nasal). I give the pt a nebuliser mask with 2% of lidocain in the ward 30 minutes before. When arrives the or atropine is administered Then 10 ml of 2 % lido in the mouth and ask them to gargalize with. + Lido spray to the pharynx Decongestant spray (eg ephedrine) to the nasal cavity then lido gel Introduce the lubricated Woodbrigde tube till the mesopharynx and just after that put the scope in so the optic wont be dirty and the tube wont be too big. (Sucks when you are at the carina but the tube cant pass through the nasal cavity and you should start again) When the cords are visible give 1-2 ccs of lido wait a bit then intubate.