Awake flexible bronchoscopic intubation

(formerly awake fibreoptic intubation)

 

Obviously, my way is the only way.

 

Decision making:

Assessment

·     Hx

·     Ix

·     Ex

Discussion

·     Patient

·     Surgeon

Informed consent

·     Procedure

·     Expectations

·     Benefits

·     Risks

·     Alternatives

 

Prepare

Drugs

·     Pre-medication + reversal

·     Topicalisation

·     Induction

·     Resuscitation

Monitoring

·     SpO2

·     NIBP

·     ECG

·     Capno

Equipment

·     Usual airway equipment

·     Difficult airway trolley

·     Flexible bronchoscope

·     Fastrach ETT 6.0

People

·     Nurse

·     Another doctor

 

Pre-medicate

Glycopyrrolate

·     4mg/kg

·     Reduce secretions -> improve topicalization

Midazolam

·     0.0125-0.025mg/kg

·     Anterograde amnesia

·     Anxiolysis

Remifentanil TCI

·     2mcg/mL during preparation

·     4-6mcg/mL at intubation

·     ↓Noxious stimulation, ↓airway reflexes

 

Pre-oxygenate

Nasal cophenylcaine

(5mg/spray)

·     7 sprays ETT side

·     3 sprays cannula side

Nasal cannula

·     2-4 L/min

 

Topicalise:

Nose

·     Cophenylcaine spray (above)

Everything

·     Nebulise 2% lignocaine 10mL

·     Flow rate 6L/min

Larynx

·     Direct vision 2% lignocaine 5mL

 

Intubate

Position

·     Patient on the operating table

·     A bit of head up

·     Stand at head of the bed in usual position

Insertion

·     Load softened fastrach 6.0 onto bronchoscope

·     Advance bronchoscope to laryngopharynx

·     Topicalise under vision

·     Wait 30 seconds

·     Advance bronchoscope to mid-trachea

·     Corkscrew ETT in

·     Keep carina in view

 

Risks of AFOI

Complication

Cause

Solution

CICO

Too much pre-med

 

 

 

Not checking capno

Early midazolam – peak effect before intubation

Titrated remifentanil – ensure spont vent

Pre-oxygenation via nasal cannula

 

Confirm placement before anaesthetising

a)      Fibreoptic scope

Capnography

LAST

Too much local

Low concentration

Staggered administration (nose -> neb -> larynx)

Epistaxis

Butcher the nose

Nasal vasoconstrictor as well as local anaesthetic

Pass bronchoscope before ETT

Then it doesn’t matter

Failure

Not enough local

Not enough pre-med

Titrate remifentanil – ensure doggo

Allow time for local anaesthetic to work

 

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