A  40  year  old  man  with  a  history  of  ankylosing  spondylitis  and  known difficulty with intubation on previous elective surgery is admitted to your ICU for hypoxic respiratory failure.   A decision to perform a semi-elective,  awake fiberoptic intubation in the ICU has been made.

Describe how you will prepare for this procedure.

[Click here to toggle visibility of the answers]

College Answer

(a)       Preparation of patient

•    Consent/explanation  of procedure
•    Obtain history of previous airway difficulty, technique used, complications, etc. (from patient,  letter  from  anaesthetist).H/o  allergies-esp.  to  local  anaesthetics.  Fasting status. Other co-morbidities, eg. coagulopathy.
•    Clinical assessment- of airway itself, mouth opening, nasal cavity/septum, range of neck movement, mental status including ability to understand and cooperate with proposed procedure, degree of hypoxia and ability to pre-oxygenate.

(b)        Preparation of environment/personnel

•    Appropriate lighting with ability to dim.
•    Monitoring - ECG, pulse oximetry, arterial line, capnography set up.
•    Adequate and working IV access
•    Establish comfortable and adequate patient position, pillows, etc.
•    Request help and ensure availability as appropriate- eg. Anaesthetist
•    Ensure presence  of adequate  skilled assistants.  Inform them in detail of steps of procedure  and  assign  roles,  as  appropriate.(eg.  observation  of  patient, administration of sedatives, optimisation of patient position, injection of LA, etc)
•    Discuss a plan B, if technique were to fail.
•    Keep  resuscitation  trolley  easily  available  and  ensure  difficult  airway  equipment available.

(d)        Preparation of drugs

•     Systemic-
o   Antisialagogue- eg. glycopyrrolate
o   Consider proton pump inhibitor.
o   Midazolam/Fentanyl  as appropriate (small doses as patient should be able to cooperate)

•    Local  anaesthetics-  Very  important  in  order  to  achieve  success.  Ensure  not  to exceed recommended doses and allow adequate time to act.
o   Nasal  cavity  and  nasopharynx-  10%  lignocaine  spray  with  phenylephrine spray or cotton tipped pledgets soaked in 4% cocaine or nebuliser filled with
5ml of 4% lignocaine.
o   Oral cavity and oropharynx- 10% lignocaine spray or 2% lignocaine viscous gargles.

•    Extra   local   anaesthetic   may   be   required   to   spray   during   advancement   of bronchoscope.

Discussion

This question separates the dual trainees in ICU and anaesthetics from those who don't routinely have their hands on a bronchoscope.

  • Preparation of equipment
    • bronchoscope is cleaned and checked
    • monitoring equipment is attached
    • Plan B equipment is at the ready (eg. cricothyroidotomy kit)
    • drugs are ready, including local anaesthetics, general anaesthetics, sedatives, opiates, muscle relaxant
  • Preparation of staff
    • skilled staff are available, and briefed about the procedure
    • backup is available, in the form of a senior anaesthetist
  • Preparation of patient
    • get consent
    • explain procedure
    • position the patient comfortably
    • administer mild sedative (eg. small dose of midazolam)
  • Preparation of airway
    • administer glycopyrrolate or atropine to dry secretions
    • spray 10% lignocaine with phenylephrine using atomiser

References

Walsh, Mary E., and G. D. Shorten. "Preparing to perform an awake fiberoptic intubation." The Yale journal of biology and medicine 71.6 (1998): 537.