A 40-year-old male with a history of ankylosing spondylitis and known difficulty with intubation with previous elective surgery is admitted to your ICU for hypoxic respiratory failure. A decision to perform a semi-elective, awake fibre-optic intubation in the ICU has been made.
Describe how you will prepare for this procedure.
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, e.g. 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.
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- e.g. Anaesthetist
- Ensure presence of adequate skilled assistants. Inform them in detail of steps of procedure and assign roles, as appropriate. (E.g. 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.
Preparation of equipment
- Check oxygen source and suction
- Check equipment for bronchoscopy- Intubating bronchoscope, light source, lubricant, suction for bronchoscope, (oxygen can be applied alternately through same port using 3-way tap) and injection port for local anaesthetic. Apply defogging solution, if available.
- Airway equipment- range of oral and nasal armoured tubes of appropriate size, oral intubating airways, soft nasopharyngeal airways, and appropriate size laryngeal mask airway. Depending on choice of oral or nasal intubation, check, lubricate and load chosen tube onto bronchoscope. Equipment required for plan B.
Preparation of drugs
- Antisialagogue – e.g. glycopyrrolate.
- Consider proton pump inhibitor.
- 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.
- 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.
- Oral cavity and oropharynx- 10% lignocaine spray or 2% lignocaine viscous gargles.
- Extra local anaesthetic may be required to spray during advancement of bronchoscope.
This question is identical to Question 21 from the first paper of 2011. The answer offered here is also identical.
- 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