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Let’s Revisit Awake Intubation
Clifford Gonzales CRNA, PhD
Wake Forest School of Medicine Nurse Anesthesia Program
Objectives
• After the presentation, participants will be able to:
Identify physical assessments for ventilation and tracheal intubation.
Describe the innervation of the airway.
State the modalities of anesthetizing the airway.
Closed Claims
• 1984- ASA Closed Claims Project
Anesthesiol. 1999; 91:552-556
Closed Claims
• 1970-2007 Closed claims analysis
Best Pract Res Clin Anaesthesiol. 2011; 25:263-276
0%
10%
20%
30%Es
op
hag
eal i
ntu
bat
ion
Inad
equ
ate
oxy
gen
atio
n/v
enti
lati
on
Dif
ficu
lt In
tub
atio
n
Asp
irat
ion
Pro
po
rtio
n o
f re
spir
ato
ry c
laim
s in
tim
e p
eri
od
(%
)
1970-1989
1990-2007
Closed Claims
1980-2011 Closed Claims Analysis
• 10,093 closed claims
• Airway injuries from general anesthesia.
https://depts.washington.edu/asaccp/pubs/herring-jc-posner-kl-domino-kb-airway-injuries-associated-general-anesthesia-closed-claims
Airway Management Closed Claims
1980-2011 Closed Claims Analysis
0%
10%
20%
30%
40%
50%
Difficult Intubation (DI) Pharyngeal/Esophageal Perforation (P/EP)
Pro
po
rtio
n o
f A
irw
ay I
nju
res
1980-1999
2000-2011
https://depts.washington.edu/asaccp/pubs/herring-jc-posner-kl-domino-kb-airway-injuries-associated-general-anesthesia-closed-claims
Closed Claims
Limitations of closed claims
Inaccurate numerator and denominator
Geographical representations
Retrospective studies
Closed Claims
Lessons from closed claims
Securing an airway is a team effort
Avoid haste with preparation (assessment, planning, communication)
Anatomy and physiology, pharmacological, and equipment knowledge needs to be current
Airway Assessment
Table 4a: Comparison of various predictive tests
Assessment Sensitivity (%) Specificity (%) PPV (%) NPV (%)
IIG 13.43 98.31 56.25 87.50
HNM 07.46 93.95 16.67 86.22
MMT 70.15 61.02 22.60 92.65
TMD 07.46 98.06 38.46 86.72
RHTMD 71.64 92.01 59.26 95.24
ULBT 74.63 91.53 58.82 95.70
IIG=Inter-incisor gap; HNM=Head and neck movement; MMT=Modified mallampatti test; TMD=Thyromental distance; RHTMD=Ratio of height to thyromental distance; ULBT=Upper lip bite test
J Aenesthesiol Clin Pharmacol, 2013, 29(2): 191-195
Airway Assessment
Assessment of ability to mask ventilate M O A N S
Mask seal Obese Age Nose, no teeth, neck mobility stiffness
Airway Assessment
Assessment of ability to intubate
L E M O N
Look externally Evaluate (TMD, RHTTMD, ULBT) Mallampati Obstruction Neck mobility
Multivariate assessment to predict DI
Difficulty Airway Algorithm • ASA Difficult Airway Algorithm
• 1. Assess the likelihood and clinical impact of basic management problems:
• Difficulty with patient cooperation or consent
• Difficult mask ventilation
• Difficult supraglottic airway placement
• Difficult laryngoscopy
• Difficult intubation
• Difficult surgical airway access
• 2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management.
• 3. Consider the relative merits and feasibility of basic management choices:
• Awake intubation vs. intubation after induction of general anesthesia
• Non-invasive technique vs. invasive techniques for the initial approach to intubation
• Video-assisted laryngoscopy as an initial approach to intubation
• Preservation vs. ablation of spontaneous ventilation
Anesthesiology 2013; 118:251-270
Difficulty Airway Algorithm • ASA Difficulty Airway Algorithm
Anesthesiology 2013; 118:251-270
Difficulty Airway Algorithm
• Unanticipated Difficulty Airway Algorithm
Brit J of Anesthet, 2015; 115(6):827-848
Awake Intubation
• Indications
Co-morbidities (cervical conditions, intolerance to apnea, etc.)
Risk of aspirations
Difficult airway assessment
Emergency
Awake Intubation
• Explanation to patient • Pharmacological • Equipment • Personnel
Awake Intubation
• Pharmacological Antisialagogue Dilators Sedation Topical anesthesia Emergency
Awake Intubation
• Equipment Airway visualization Adjuncts Monitors Emergency
Awake Intubation
• Personnel Other anesthesia providers Surgeon/s Nurses
Awake Intubation
• Various local anesthetics (LA) can be used for anesthetizing the airway.
• Lidocaine has an advantage because of:
Availability of different formularies and preparation.
Wider margin of safety
Awake Intubation
Airway innervation • Nasopharynx- Trigeminal nerve
(opthalmic and maxillary branch) • Oropharynx- CNIX
(Glossopharyngeal nerve) • Laryngopharynx- superior
laryngeal nerve • Larynx and trachea- recurrent
laryngeal nerve
Common Methods of Anesthetizing the Airway
Nasopharynx
• ½ in of lidocaine 5% at each nares (50mg)
OR
• 2 ml Lidocaine 4% aerosol spray (80mg)
Common Methods of Anesthetizing the Airway
Oropharynx •Apply 2 inches of 5% Lidocaine ointment on a tongue depressor (200mg)
OR • Instruct patient to gurgle 5 ml of
Lidocaine 4% topical solution (may need to do this twice) (200 mg or 400mg)
Common Methods of Anesthetizing the Airway
Oropharynx
OR • Place ½ in. of 5% lidocaine at a cotton tip
applicator and apply it at the base of palatoglossal arch (5 min each side) (100 mg)
OR • Using a 22g spinal needle, administer 2% of
Lidocaine injection solution to both bases of the palatoglossal arch (80mg)
Common Methods of Anesthetizing the Airway
Laryngopharynx (Superior Laryngeal Nerve) •Administer 5 ml of 4% lidocaine injection solution via nebulization (200 mg)
OR •Drip 5 ml of 2% lidocaine viscous solution to the back of the patient’s tongue (1-2 min) (200mg)
Common Methods of Anesthetizing the Airway
Laryngopharynx (Superior Laryngeal Nerve) OR
• Using a 23 G needle, administer 3 ml of 2% lidocaine injection solution at both lateral sides of the neck between the thyroid cartilage and hyoid bone (120mg).
Common Methods of Anesthetizing the Airway
Recurrent Laryngeal Nerve • Lidocaine nebulization may suffice
OR • Using epidural cath through the fiberoptic,
5ml of lidocaine 4% to the trachea (200mg) OR
• Using a 20 G needle, administer 5 ml of 4% lidocaine injection solution to the Cricothyroid membrane (200mg)
Awake Intubation
Calculation of lidocaine total administered dose: 1. Nasopharynx (ointment)= 50mg 2. Glossopharyngeal nerve= 80mg 3. Superior Laryngeal nerve= 120mg 4. Recurrent Laryngeal nerve=200mg Total without nasopharynx = 400mg Total with nasopharynx = 450mg
Awake Intubation
Lidocaine toxicity
• Legendary: 5mg/kg
• Normal therapeutic range for ventricular arrythmias: 2-5mcg/ml
• Various pharmacological factors affect lidocaine plasma level
Awake Intubation