Airway Management II: Lecture 3 - Fiberoptic Intubation

Question 1

Which medication should be given earliest when deciding to perform an Awake Intubation?

Answer 1

Robinul - wants to be given the earliest to make sure it is dry so secretions do not mess with topical anesthetic

Versed - yes given early, but not the earliest, will be given in a titrate to effect deals, patient dependent

Lidocaine - will be part of Awake Intubation kit, but given a little bit before, and during the procedure (several times due to topically does not last long)

Fentanyl - want to avoid as don’t want any respiratory suppression, why you are doing the Awake Intubation, will be situation dependent

Reglan - not really used for awake intubation

Versed is a sedative that aids in patient comfort during procedures.

Question 2

Which local anesthetic has a dual benefit for preparation of a patient for awake nasal intubation?

Answer 2

Cocaine - because of its vasoconstriction properties, very rarely used

Other options were… but none have vasoconstriction properties:
Lidocaine
Tetracaine
Ropivacaine
Benzocaine

Lidocaine is commonly used for its effectiveness in both topical and injectable forms.

Question 3

If coughing is contraindicated, which nerve block should be avoided?

Answer 3

Transtracheal n. block… it makes people cough

Other options:
SLN n. block
Glossopharyngeal n. block
Sphenopalatine ganglion block

This block can induce coughing, which may be undesirable in certain clinical situations.

Question 4

Which of the following would provide the most complete coverage for an Awake Intubation?

Answer 4

Nebulized

Other options:
Transtracheal
Glossopharyngeal
SLN

Transtracheal blocks are effective for anesthetizing the trachea and larynx.

Question 5

What is the construction of a fiberoptic bronchoscope?

Answer 5

Fiberoptic bundles and cables encased in a slender, waterproof sheath

Light source super important

This design allows for flexibility and maneuverability during procedures.

Question 6

Manipulating the Fiberoptic Scope

Answer 6

The cable system permits manipulation of the tip of the bronchoscope by adjustments at the handle

Question 7

Parts of the Fiberscope Bronchoscope

Answer 7

KNOW THE PARTS!!!

Question 8

List some indications for Fiberoptic Bronchoscopy.

Answer 8

• Routine Intubation (best way to get better at it)
• Difficult airway management
  Known or anticipated
  Unanticipated failed intubation
  Compromised Airway
  Upper airway
  Lower airway
• Intubation of the conscious patient preferred
  High risk of aspiration
  Movement of neck not desirable
  Known difficult mask ventilation
  Morbid obesity
  High risk of dental damage
• Previous tracheostomy or prolonged intubation

Fiberoptic bronchoscopy is essential in various clinical settings for airway management.

Question 9

Contraindications for FOB

Answer 9

Lack of skill

Lack of functioning equipment

Inability to oxygenate patient

Major bleeding or secretions in the airway

Patient refusal (#1 reason (that is typically #1 answer for anything)

Question 10

Advantages of FOB

Answer 10

Excellent visualization of the airway

Minimal hemodynamic stress when properly performed

Allows for visualization of the airway without manipulation of the head and neck

Oral or nasal intubation is possible in the adequately prepared patient

Ability to apply topical anesthesia and insufflate oxygen during intubation process

Question 11

Disadvantages of FOB

Answer 11

Expensive

Requires careful maintenance/sterilization process

Presence of blood/secretions impairs visualization

Requires practiced expertise for use in acute situations

AFTER 10 SUCCESSFUL INTUBATIONS ALL PROVIDERS SHOULD BE SUCCESSFUL 90% OF THE TIME

Question 12

Special Features

Answer 12

Allows visual evaluation of all airway passages

Applicable to all age groups

Adaptable with other airway devices/techniques

Question 13

Overall Picture of Procedure

Answer 13

One of the ways it is done

Typically done in the sitting position with provider in front of them (30 degrees off to side)

Question 14

Rigid Fiberoptic Bronchoscopy

Answer 14

Anatomically shaped or straight

Used by surgeons for:
Direct laryngoscopy
Microlaryngoscopy
Mediastinoscopy

Device names
Bullard
Upsher
Wu

Question 15

Video Laryngoscopy

Answer 15

Fiberoptic + Laryngoscope

Question 16

Awake vs Asleep FOB

Answer 16

Awake
Airway patency and tone maintained
Patient is spontaneously ventilating
Decreased risk of aspiration
If it fails, patient still safe and stable
*** Picture is how typically done in sitting position

Asleep
Minimal patient discomfort
Requires no cooperation from patient
Can position patient for practitioner

Question 17

What is crucial for the preparation of Awake Intubation?

Answer 17

Preparation, Preparation, Preparation

Psychological preparation: informative, reassuring preop visit

Pharmacologic preparation
Premedication
Light or no sedation for calm pts
Heavy sedation for anxious pts
Narcotics when pain is present
Specific drugs for habitual drug users
Antisialagogue unless contraindicated

Preparation of the patient
* IV sedation
No sedation for anxious pts w/ severely compromised airway
Minimal sedation for most patients
Heavy sedation for uncooperative patients
* Topical anesthesia
Oral intubation: oropharynx, laryngotracheal
Nasal intubation: nasal mucosa, laryngotracheal
Monitoring and oxygen

Expert endoscopist

Functional fiberoptic bronchoscope and supplies

Thorough preparation enhances the safety and efficacy of the intubation process.

Question 18

What is the typical time required for Awake Intubation preparation?

Answer 18

~30 min

Not something that can be done in a rush

Rushing this process can compromise patient safety and comfort.

Question 19

What is one key psychological preparation step for patients undergoing Awake Intubation?

Answer 19

Informative, reassuring preoperative visit

NEED INFORMED CONSENT
May be uncomfortable
Patient needs to understand options and risks
They are a difficult airway
Remembering the procedure (recall)

This helps alleviate patient anxiety and promotes cooperation.

Question 20

Awake Intubation Preoperative Visit

Answer 20

Review old anesthesia records for:
Degree of difficulty of endotracheal intubation (difficulty
encountered and method used)
Positioning of the pt. during laryngoscopy (sniffing position, etc.)
Equipment used
Familiarity with previous techniques

Conduct an empathetic interview

Question 21

Contraindications to Awake Intubation

Answer 21

Patient Refusal

Inability to Cooperate
Child
Mentally challenged patient
Intoxicated, combative patient

Documented true allergy to all anesthetics

Question 22

Drugs Needed for Fiberoptic Intubation (Adult)

Answer 22

Glycopyrrolate – 0.2-0.4mg (*1st premedicant)
Antisialagogue

Midazolam (titrate to effect)
antegrade amnesia

Aspiration prophylaxis
H2 antagonists, nonparticulate antacids, Reglan

Mucosal vasoconstrictors if nasal
Cocaine (great local anesthetic for nasal cases but obviously heavily regulated usage, and therefore rarely used)
Afrin spray (Oxymetazoline)
Epinephrine
Phenylephrine

Local anesthetics of choice
Lidocaine, cetacaine, etc.

Question 23

What type of sedation is typically used for calm patients during Awake Intubation?

Answer 23

Light or no sedation

Minimal sedation is preferred to maintain patient responsiveness.

Question 24

What is the function of an antisialagogue in the context of Awake Intubation?

Answer 24

To reduce secretions

This enhances the effectiveness of local anesthetics and improves visualization.

Question 25

What equipment is needed for an Adult Awake Fiberoptic Intubation?

Answer 25

* Endotracheal tubes in assorted sizes * Oral airways, intubating airways, nasal airways * Fiberoptic scope and light source * Suction device * O2 delivery system * Monitors ## Footnote Having the right equipment ready is vital for a successful intubation.

Question 26

Method for an Adult Awake Fiberoptic Intubation

Answer 26

Take patient to OR that is prepared for difficult airway Have fiberoptic scope, drugs, and all devices ready Monitor the patient Supply patient with O2 via nasal cannula Position patient Pillow ramp Lower OR table, get step stools if needed Apply topical anesthetic to tongue and mouth Lidocaine ointment Lidocaine nebulizer If nasal apply topical pledgettes Sedate patient with midazolam as appropriately indicated by vitals and airway condition *** VERY KEY STEP, DO NOT OVER SEDATE and make the situation stressful when does not need to be Perform choice of nerve blocks Translaryngeal Glossopharyngeal Superior Laryngeal ...Fiberoptic insertion

Question 27

Step by Step for Fiberoptic Insertion

Answer 27

Question 28

Step by Step for Fiberoptic Removal after ET Tube Placement

Answer 28

Question 29

Commonly Used Awake Intubation Local Anesthetic Drugs

Answer 29

Lidocaine 2% viscous solution (swish through mouth, coat nasal trumpets) 5% ointment (apply to tongue, oropharynx using tongue depressor) 4% solution (spray, atomize, nebulize, inject into trachea) 2% solution (superior laryngeal, glossopharyngeal nerve block) 1% solution (glossopharyngeal) 10% topical spray Cocaine 4% solution (soak q-tips, pledgets for nasal application/vasoconstriction) Tetracaine 0.5%, 1%, and 2% Benzocaine (Cetacaine), other oral sprays apply to tongue, oropharynx Be aware of toxic doses of local anesthetics!!

Question 30

Specific Areas to Anesthetize

Answer 30

Anesthesia of the Nasal Mucosa and Nasopharynx (Nasal Intubation) SPHENOPALATINE GANGLION and ANTERIOR ETHMOIDAL NERVE Topical Anesthesia of the Mouth, Oropharynx and Base of Tongue GLOSSOPHARYNGEAL NERVE BLOCK SUPERIOR LARYNGEAL NERVE BLOCK Topical Anesthesia of the Hypopharynx, Larynx and Trachea SUPERIOR LARYNGEAL NERVE = SLN block RECURRENT LARYNGEAL NERVE = TRANSTRACHEAL BLOCK There is no single nerve that can be blocked to provide complete anesthesia for the airway!

Question 31

Nerves and Span of the ET Tube

Answer 31

Question 32

Topical Airway Anesthesia

Answer 32

Secretions can dilute and wash away local anesthetic for topical anesthesia Antisialagogues can improve the effectiveness of topical agents (surface needs to be dry, think sanding down wood to create surface for the paint to stink to) Glycopyrrolate is a good antisialagogue that causes minimal tachycardia Direct spray of topical local anesthetics to the nose can be uncomfortable Topical anesthesia of the nose and nasopharynx may be accomplished by directing the patient to inhale nebulized local anesthetic 4 ml of 4% lidocaine may be used

Question 33

Topical Airway Anesthesia Application

Answer 33

Sensation from the nasal mucosa and nasopharynx are supplied by branches of the Trigeminal nerve Sensation from the oral mucosa and oropharynx are supplied by branches of the Glossopharyngeal nerve Topical anesthesia of the mouth and oropharynx may be accomplished with topical sprays such as cetacaine spray and 10% lidocaine spray Cetacaine – benzocaine & tetracaine mixture. → toxic dose just over 1mg/kg → methemoglobinemia Local anesthetics are absorbed through the mucosa Sprays take several minutes to provide anesthesia and must be applied repeatedly for best effect... and short duration action means will be applied repeatedly

Question 34

What is one method for providing topical anesthesia for nasal intubation?

Answer 34

Application of long cotton-tipped applicators soaked in local solution ## Footnote This method ensures effective coverage of the nasal mucosa.

Question 35

Anesthesia of the Nasal Mucosa and Nasopharynx

Answer 35

To provide the initial steps for blunting of airway reflexes associated with awake nasotracheal, oropharyngeal and fiberoptic intubations. Drugs: 4% Lidocaine with epinephrine (or cocaine is a 4% solution – max. 200 mg in adult), or mixture of Lidocaine 3% and Phenylephrine 0.25%) Anatomy: Sensation is via the middle division (V2) of the Trigeminal nerve (CN V), which lies below the nasal mucosa, posterior to the middle turbinate. Innervation to the nasal mucosa and nasal cavity involves the sphenopalatine ganglion (Meckel’s or pterygopalatinum ganglion) and the ethmoid nerve. Patient Position: Patient is most comfortable when head of bed is elevated approximately 30˚

Question 36

Anesthesia of the Nasal Mucosa and Nasopharynx Complications

Answer 36

Additionally, nasal airways, in increasing sizes, can be lubricated with Lidocaine 2-5% jelly, and passed into the nostril being intubated for additional patient comfort. These procedures allow for blocking of the sphenopalatine ganglion (or Meckel’s ganglion) and the ethmoid nerve. Assessment of Block Efficacy: Patient tolerates introduction of nasal airways and/or nasal intubation. Complications: Epistaxis Systemic toxicity Loss of protective laryngeal reflexes may place patient at increased risk for aspiration.

Question 37

What is the role of the glossopharyngeal nerve in Awake Intubation?

Answer 37

Supplies sensation from pharyngeal and oral mucosa and posterior tongue Nerve exits the skull via the jugular foramen and travels with the vagus nerve, internal carotid artery and internal jugular vein in the carotid sheath ## Footnote Understanding nerve supply is crucial for effective nerve blocks.

Question 38

Glossopharyngeal Nerve Block Process

Answer 38

The intraoral glossopharyngeal block is best accomplished after topical anesthesia of the tongue The patient is asked to stick out tongue and the tongue is displaced laterally with a tongue blade Place a 22 gauge, 9 cm needle at the inferior portion of the posterior palatopharyngeal fold (tonsillar pillar) just deep to the mucosa Aspirate prior to injection of the local anesthetic to avoid intravascular injection With correct placement, inject 1-2 ml of local anesthetic Repeat the procedure on the other side

Question 39

Superior Laryngeal Nerve Block

Answer 39

The superior laryngeal nerve is a branch of the Vagus nerve Travels just inferior to the greater cornu of the hyoid bone Divides into internal and external branches to provide sensation to the anterior and posterior epiglottis and laryngeal mucosa to the level of the vocal cords

Question 40

Superior Laryngeal Nerve Block Process

Answer 40

Firmly displace the hyoid bone towards the side to be blocked, even if it causes the patient some minor discomfort. Use small amounts of sedation to offset patient discomfort. Exercise caution - not to insert the needle into the thyroid cartilage, since injection of local anesthetic at the level of vocal cords may cause edema and airway obstruction. If air is aspirated, laryngeal mucosa has been pierced, and the needle needs to be retrieved. If blood is aspirated (superior laryngeal artery or vein), the needle needs to be redirected more anteriorly. Pressure should be applied to avoid hematoma formation.

Question 41

Superior Laryngeal Nerve Block on Human

Answer 41

Question 42

What type of nerve block should be avoided if coughing is undesirable?

Answer 42

Transtracheal Nerve Block Placement of local anesthetic within the larynx can provide anesthesia of the larynx and trachea below the vocal cords Sensation to this area is supplied by the recurrent laryngeal nerve, a branch of the vagus nerve ## Footnote This block can trigger coughing reflexes, complicating the intubation process.

Question 43

Transtracheal Nerve Block Process

Answer 43

Patient Position: Supine, with neck hyperextended (or pillow removed and extended). Technique: Inform the patient about the procedure, what is expected of them, and likelihood of coughing. Anesthetist should be in position to place index and third fingers of the non- dominant hand in the space between the thyroid and cricoid cartilages (identifying the cricothyroid membrane). The trachea can be held in place by placing the thumb and third finger on either side of the thyroid cartilage. The midline should then be identified and injected lightly to create a local skin wheal (using a 22-guage or smaller needle). A 10 ml syringe containing 4% lidocaine (or other desired concentration), is mounted on a 22-guage, 35 mm plastic catheter over a needle, and is introduced into the trachea. The catheter is advanced into the lumen, midline thru the cricothyroid membrane, at an angle of 45 degrees, in a caudal direction. **Immediately after the introduction of the catheter into the trachea, a loss of airway resistance and aspiration of air confirms placement, and the needle is removed from the catheter.** The patient is then asked to take a deep breath and then asked to exhale forcefully. At the end of the expiratory effort, 3-4 ml of local anesthetic solution is rapidly injected into and over the back of the trachea. This will usually cause patient to first inhale to catch his or her breath and then forcefully cough, spreading the lidocaine over the trachea, making distal airway anesthesia more predictable. This area is nearly devoid of major vascular structures.

Question 44

Transtracheal Nerve Block Technique Tips

Answer 44

Caution - If a regular needle is used to inject (rather than a catheter), the lidocaine is injected rapidly and the needle is removed immediately!!! Surrounding structures, including the posterior tracheal wall can be damaged if the needle is not stabilized during injection of the local anesthetic and then be removed immediately!

Question 45

Nerve Blocks by Anatomy

Answer 45

Nasal Cavity and Nasopharynx Sphenopalatine n. block Anterior ethmoidal n. block Oropharynx Glossopharyngeal n. block Larynx SLN block Trachea and Vocal Cords Translaryngeal (transtracheal) anesthesia

Question 46

What are some common complications of nasal airway anesthesia?

Answer 46

* Epistaxis * Systemic toxicity * Loss of protective laryngeal reflexes ## Footnote Awareness of these risks is essential for patient safety.

Question 47

What is the purpose of using topical airway anesthesia during Awake Intubation?

Answer 47

To blunt airway reflexes associated with intubation ## Footnote This helps facilitate the procedure and improve patient comfort.

Question 48

What is the anatomical significance of the sphenopalatine ganglion in nasal anesthesia?

Answer 48

It supplies sensation to the nasal mucosa and nasal cavity ## Footnote Targeting this ganglion can enhance anesthesia effectiveness.

Question 49

What is the technique for a glossopharyngeal nerve block?

Answer 49

Place a 22 gauge, 9 cm needle at the inferior portion of the posterior palatopharyngeal fold ## Footnote Correct placement is crucial to avoid complications.

Question 50

What is the role of the superior laryngeal nerve?

Answer 50

Provides sensation to the anterior and posterior epiglottis and laryngeal mucosa ## Footnote Understanding this innervation is important for effective anesthesia.

Question 51

What is an important consideration when performing a transtracheal nerve block?

Answer 51

Ensure the needle is stabilized during injection ## Footnote This prevents injury to surrounding structures.

Question 52

Fill in the blank: The _______ nerve is a branch of the vagus nerve that provides sensation to the larynx.

Answer 52

Superior Laryngeal ## Footnote Understanding the anatomy helps in performing effective nerve blocks.

Question 53

What is the term for the nerve block involving the sphenopalatine?

Answer 53

Sphenopalatine n. block

Question 54

Which nerve is blocked during the anterior ethmoidal nerve block?

Answer 54

Anterior ethmoidal n.

Question 55

What is the anatomical region associated with the glossopharyngeal nerve?

Answer 55

Oropharynx

Question 56

Which nerve block is associated with the larynx?

Answer 56

SLN

Question 57

What is the procedure used for anesthesia of the trachea and vocal cords?

Answer 57

Translaryngeal (transtracheal) anesthesia

Question 58

What is the state of being anesthetized referred to as?

Answer 58

Asleep

Question 59

What technique is used for intubation without the need for airway anesthesia?

Answer 59

Anesthetized = Asleep Fiberoptic Intubation No need for airway anesthesia Blocks Topical Must Preoxygenate!!

Question 60

Flexible Fiberoptic Tips

Answer 60

Proper topicalization of the awake/sedated patient “Jawthrust” Use of oral/nasal airways or introducers Practice, practice, practice!

Question 61

What technique can be used to help with airway management during intubation?

Answer 61

Jawthrust

Question 62

What is the key to improving fiberoptic intubation skills?

Answer 62

Practice, practice, practice!

Question 63

Flexible Fiberoptic Reminders

Answer 63

Always be aware of your position and the curve of the scope Remember that bending damages the fiberoptic tubes of the scope If the patient is awake be professional and calm Don’t forget to sedate and/or start the general anesthesia after the tube is placed!