a problem based approach to awake flexible optical intubation€¦ · g. 7. after passing the vocal...

Inhoudsopgave1. Summary2. Introduction3. BasicPrinciples4. ScopeHandling5. Overview6. AProblemswithvisibility

a. 1.Thereiscompletewhite-outofthelensb. 2.Foggingofthelensc. 3.Thereisnovisibilityatalloraredd. 4.Secretionsormucousobscuresvisibilite. 5.Fieldofvisionappearstoosmallf. 6.Imageblurredonmonitorg. 7.Afterpassingthevocalcordswiththe

7. BTechnicalproblemsa. 8.YourDepartmentofAnaesthesiahasfinab. 9.Suctionisnotworkingc. 10.Lossoflightsource

8. CProblemswithadvancementofthetracheaa. 11.Thetrachealtubecannotpassthenoseb. 12.PoorcontroloftheETT,tubekeepsslc. 13.Unabletomanoeuvretheendoscopetowad. 14.Scopestickingtotrachealtubee. 15.Thetubecannotbepassedthroughthef. 16.Tipoftheflexibleopticalscopecanng. 17.Thedistalinsulationrubberprotectio

h. 18.ThenasalRAE™tubeistoolongandthi. 19.Thebronchoscopeisinadvertentlypassj. 20.Aftercorrectintubationofthetrachek. 21.Cannotadvancethetubeduringoralin

9. DProblemswithtopicalisationoftheuppea. 22.Thepatienthasalaryngealspasmafteb. 23.Inadequatetopicalisationc. 24.Theairwayisnotanaesthetizedatalld. 25.Thepatientexperiencesanacuteuppere. 26.“Spray-as–you-go”(SAYGO)techniquenof. 27.Thepatienthasanknownallergytolig. 28.Almosttotalairwayocclusionoccursr

10. EBleedingproblemsa. 29.Themucosaorintraoraltumourstartsb. 30.Epistaxisdirectlyafterintroduction

11. FOxygenationproblemsduringAFOIa. 31.Patientdesaturatesbeforeorshortly

12. GAnatomicalproblemsa. 32.Alargesupraglotticmassortheepiglb. 33.Itisnotpossibletofindandidentifc. 34.Themouthopeningislessthan2.5cend. 35.Thelarynxisdeviatedanteriorly,whie. 36.Itisnotpossibleorcontra-indicatedf. 37.Cannotgetintravenousaccess,buthavg. 38.Theairwaydiameterappearstobetooh. 39.Itisimpossibletopassthebaseoft

13. HProblemswithsedationa. 40.Thepatientisunconscious

b. 41.Thepatientbecomesapnoeicduringthe14. IProblemswithpatientcooperation

a. 42.Thepatientisaggressiveb. 43.ThepatientstartsvomitingduringAFOc. 44.Thepatientissneezingcontinuouslyad. 45.Thepatientbitesontheinsertioncore. 46.Thepatientrefusesanawakeintubatio

15. JProblemswithflexibleopticalscopesina. 47.Itisimpossibletopassthefiberscopb. 48.ItisimpossibletoadvancetheETTthc. 48.ItisimpossibletoadvancetheETTthd. 49.ThetrachealtubecanpasstheLMAbue. 50.Yourplanistoperformanoralflexib

16. KVentilationoroxygenationproblemsaftea. 51.Aftervisualcorrectplacementoftheb. 52.AfterintubationwithanMLTtubeitic. 53.AfterAFOIandtheuseofaRAEnasald. 54.Aftervisualguidedflexibleintubatio

17. LLogisticproblemsa. 55.Icannotstandbehindthepatientbecab. 56.Theheadandnecksurgeonhasnotyetc. 57.DuringtheAFOIyourpresenceisurgend. 58.Therearenotenoughpatientsinmysue. 59.Duringtheadvancementprocedureofth

18. MExtubationproblemsa. 60.TheAFOIwasverydifficultanditis

19. Discussion20. Conclusions

21. References

Aproblembasedapproachtoawakeflexibleopticalintubation“Everythingyoualwayswantedtoknowaboutawakeflexibleopticalintubationbut

wereafraidtoask…”

JohannesMHuitink,MDPhD1,NaveenEipe,MD2,AdrianoCocciante,MD,FANZCA3,RalfKrage,MD,PhD1,RenySegal,MD,FANZCA4

DepartmentofAnaesthesiology,VUUniversityMedicalCenter,Amsterdam,TheNetherlands1

DepartmentofAnaesthesiology,theOttawaHospital,Ottawa,Canada2

DepartmentofAnaesthesia.WesternHealth,Footscray,Melbourne,Victoria,Australia3

DepartmentofAnaesthesiaandPainManagement,RoyalMelbourneHospital,Parkville,Victoria,Australia4

PublicationofthisbookwassupportedbytheMobileAnaesthesiologyServiceHollandFoundation.TheauthorsandtheAirwayManagementAcademy(www.airwaymanagementacademy.com)areresponsibleforthecontent.

Addressforyourcommentsorfeedback:Dr.J.M.HuitinkVUUniversityMedicalCenterDepartmentofAnaesthesiologyPOBox7057

1007MBAmsterdam,theNetherlands

Editing:Dr.J.H.BretschneiderFirstedition,September2013AmsterdamISBN:978-94-6228-248-3

NUR:871

Allrightsreserved.

Thisworkmaynotbetranslatedorcopiedinwholeorinpartwithoutthewrittenpermissionoftheauthors.Whiletheadviceandinformationinthisbookarebelievedtobetrueandaccurateatthedateofgoingtopress,neithertheauthorsnorthesponsorcanacceptanylegalresponsibilityforanyerrorsoromissionsthatmaybemade.Theauthorsmakenowarranty,expressorimplied,withrespecttothematerialcontainedherein.

Summary

Awakeflexibleopticalintubation(AFOI)forairwaymanagementisavaluabletechnique,whichhasundergoneseveraltechnicalimprovementsandadaptationsovertime.Despitethistechniquebeingadvocatedbyanaesthesiaandairwaymanagementexpertgroupsaroundtheworldasagoldstandardformanagementoftheexpecteddifficultairway,manyanaesthesiologistsarenotcomfortableusingthetechnique.Thismaybebecauseofalackofexperience,expertiseorinappropriateequipment.TheremayalsobedeficienciesintrainingandclinicalAFOIpracticeopportunities.

InthisbookadviceandtipswillbegiventoimprovetheintubationsuccessrateandsatisfactionofairwaymanagementwithAFOI.WethinkthatthisbookwillhelpimprovetheAFOIexperienceofboththeclinicianandthepatientandultimatelyleadtoimprovedairwaymanagementusingAFOI.WewillsummarizeboththefrequentandrarecausesforfailureofAFOI.Donotbeafraidtoaskthingsthatyoualwayswantedtoknow.

July2013,

Amsterdam:JohannesHuitinkandRalfKrageOttawa:NaveenEipe,

Melbourne:AdrianoCoccianteandRenySegal

R.KrageandN.Eipe

J.HuitinkenR.Segal

A.Coccicante

Introduction

EnthusiasmamonganaesthetiststoundertakeanAFOIrangesfrom“scaredtodeath”through“reluctant”to“hopeful”,withasmallnumberofcolleaguesinthe“confident”group.Thismaybeduetothelackoftheinitialandintensivetrainingrequiredtoacquirethisskill,lackofskillmaintenanceorpoorequipment.Inappropriatepatientselection,difficultpathology,inadequatepreparationofequipmentorpatient,orfailuretorecognizecontraindicationsandpotentialcomplicationsofAFOIaresomeoftheotherfactorsthatmayleadtofailureoftheAFOItechnique1-3.

ThesedifficultiesarefrequentlyencounteredandarethereasonAFOIstillhasafailurerateof0.5-13%4-7.ItistheopinionoftheauthorsthatallphysicianswhomanagepatientairwaysneedtobegoodatAFOI,becausetheywillsomedayintheircareerencounterapatientthatcannotbesafelyintubatedbyothertechniques.Thisreviewisnotanotherarticlefrom‘airwaymanagementmavericks’for‘airwaymanagementdummies’,butasharingofourexperienceswithAFOI.

WethinkthatmanyproblemsfacedduringAFOIcanbeprevented.Wehaveencounteredmanyoftheseproblemsourselvesduringouranaestheticpractiseatmajorcancercentres,publicandruralhospitalsanduniversitymedicalcentresintheNetherlands,Germany,SouthAfrica,Canada,AustraliaandIndiaandduringnumerousworldwideairwaytrainingsessionswithtraineesandcolleagues.WewillfocusonpotentialproblemsthatcanbeencounteredduringAFOI.Wehavetriedtodocumenttheseproblemsasthoroughlyaspossible,withaliteraturesearchand,whereapplicable,photodocumentation.Wehavealsotriedtogivetipsthatcanbeapplicableinmedicalcentresinanypartoftheworld.Itisourhopethatthesetipsmay

helptheanaestheticcommunitytoembraceanairwaymanagementtechniquethatcanbelifesavingwithconfidence.

WethinkthatthisbookisuniqueastoourknowledgethereisnotasingledocumentavailablethataddressesalltheseproblemsrelatedtoperformingAFOIwhilstatthesametimeofferingpracticalsolutions.

Video1

introductiontoAFOI

00:00/00:00

Video2

basictechniques

00:00/00:00

BasicPrinciples

Wewillusethetermawakeflexibleopticalintubation(AFOI).AnAFOIcanbeperformedwithaflexiblefibreopticscopeorwithaflexiblevideoscopewitha“chipinthetip”.Newhybridscopetechniquesarealsousedthatcombineflexibleopticalsandvideo.Themostcommonlyusedtermintheliteratureisawakefibreopticintubation.WethinkAFOIismoreappropriatenowadays.ThefollowingbasicprinciplesofAFOIhavebeendevelopedforandareroutinelyusedinourteachingandtrainingprograms8-9.Itcannotbestressedoftenenoughthatthesebasicprinciplesshouldbecarefullyobservedandadheredto.

•Preparethoroughlyanddiscusstheplannedprocedurewiththepatientandotherco-workers.

•Ensurethatthepatientfullyunderstandstheprocedureandisfullycooperative.

•AlwaystrytodoanAFOIprocedurewithtwoexperienceddoctors.

•Makesuretheindicationfortheawakeprocedureissound(Fig.1).

Fig.1

•Shareyourthoughtsofyourplanwithacolleague.

•EnsurethatAFOIisnotcontraindicatedwhilstensuringthatthepatientandpathologyaresuitableforAFOI(Fig2).

Fig.2

•Knowexactlyhowtoassembleyourequipmentandcheckthatitisfunctioning.

•KeeppractisingAFOIforconservationofyourskillsovertime.

•Topicalisetheupperairwayinaneffective,safeandeasyway.

•AFOIshouldneverbeperformedinahurryasthiswillgreatlydecreasethechanceofsuccessfultrachealintubation.

•IfyouarenotveryexperiencedwithAFOIstandbehindthepatient.Doingaprocedurefrombehindthepatientmakestheprocedureeasier.Standingbehindthepatientis:safer(noclosecontactwiththepatientwhowillcoughorspitintoyourfaceifyouareunlucky),andeasier(leftisleft,rightisright)andyoucansimultaneouslywatchthemonitorsandsurroundings.Werecommendstandingbehindthepatient,butalsoteachthe“facetofacetechnique”,becauseinsomesituationsstandingorsittinginfrontofthepatientmaybetheonlywaytoproceed,forexampleinsevererespiratorydistresswhenthepatientcannotliedown.

•Ensurethatyouhaveacontingencyairwaymanagementplan,shouldAFOIfail;haveaplanBandCavailableforemergencyairwaymanagement,andmakesureallteammembersarebriefedbeforeyoustarttheprocedure.

•IfyouthinkAFOI,performAFOI

•DoatimeoutprocedurewithyourteamanddoafinalchecklistbeforeyoustarttheAFOIprocedure(seeFig3).

Fig.3

•MemorizethebasicFFFFIberopticintubationprinciplestoguideyouthroughtheprocedure(seeFig.4).

Fig.4

Photo1

difficultintubationtrolley

Photo2

storageboxclosed

Photo3

storageboxopen

Photo4

sizeoftrachealtubetoobiginrelationtofibrescope

Photo5

flexiblescopetipmovent1

Photo6

flexiblescopetipmovent2

Photo7

flexiblescopetipmovent3

Photo8

flexiblescopetipmovent4

ScopeHandling

Morethan80%ofscopemanipulationcomesfromflexingandextendingthewristandthusrotatingthescopehandle.Thishandlerotationmusttranslatetothetipofthescope.Theremaining20%ofscopemovementisachievedbyflexingorextendingthescopetip(achievedbymovingthethumbleveronthescopehandleupordown)andbyscopeinsertion(insertingthecordofthescope).Thescopecannotberotatedfromthetiporthecord,whichisexposedatthepatient’smouthornose.Thescopemustberotatedfromthehandle.Thetipofthescopeisthepartinthepatient’sairwayandhencethetrue“eye”ofthescope,theimageofwhichisthenprojectedontheeye-pieceorscreenifacameraisused.Forthemovementinthehandletofullytranslatetothetip,thecordmustbestraightatalltimes.Anybendorloopinthecord,whichiseasytodoandoverlookinclinicalendoscopy,willcausealessthanequaltranslationofhandlemovementtotipmovement.Thehandlemovementneedstobecoupledtotipmovementinaonetooneratio,notless.Thiswillfrustratetheendoscopist’sabilitytodriveandaccuratelydirectthescope.Thesecondcrucialtechniqueinscopedrivingis,asalreadydescribedabove,havingthenext“target”(theairspaceonthewaytothelarynx,thelaryngealinlet,thecentreofthetrachea,whicheveristhenexttargetintheendoscopysequenceatthetime)centredintheviewfinderorscreen.Toconstantlykeepthetargetinthecentreoftheviewfindertheendoscopeshouldbedriveninthreedistinctphasesknownas“Stop,Centre,Move”(Fig.5).MethodsusedattheRoyalMelbourneHospital,AustraliaandatVUUniversityMedicalCentre,Amsterdam,TheNetherlands.

VIdeo3

facetofaceintubation

00:00/00:00

Fig.5

Photo9

OlympusTMMAF-scopescreen

Photo10

StorzTMTelepackmonitorscreen

Photo11

mobilelightsource

Overview

Incidentsandproblemsmayoccurindifferentways:themostcommonproblemscanbecategorizedinanyofthefollowingcategories4-7,10,11:

AproblemswithvisibilityBtechnicalproblemsCproblemswithadvancementofthetrachealtubeDinadequateupperairwaytopicalisationEbleedingproblemsFoxygenationproblemsduringAFOIGanatomicalproblemsHproblemswithsedationIpoorpatientcooperationJproblemswithflexibleopticalscopesincombinationwithanotherairwaydeviceKventilationoroxygenationproblemsafterintubationLlogisticproblemsMextubationproblems

AProblemswithvisibility

1.Thereiscompletewhite-outofthelensoronthemonitorscreen

•WhenanAFOisdonewithacameraorvideobronchoscope,awhitebalancemustbeperformedbeforeyoustart.

•Decreasethelightintensitymanuallytopreventlightscatterfromilluminationofsaliva

•Onlyuseclearwatersolublelubricationorsiliconelubricationonthefibre-opticscopemakingsurethatthelenstiphasbeenwipedcleanbeforeproceeding.

2.Foggingofthelens

•Thisiscausedbydifferencesintemperaturebetweenthecoldbronchoscopeandthewarmpatient.Thiscanbepreventedby:•Preheatthescopeinwarm

waterbeforestartingtheprocedure,orhavethescopeonforafewminutesbeforestartingtheprocedure.

•Wait10secondsafterintroducingthescopethroughthenose.

•Trytotouchthebuccalmucosagentlywiththetipofthescopetospeeduptemperatureequilibration.

•Useanti-fogsprayorsoapwatertoclearthelens.

•Neverspraythetipofthebronchoscopeortubewithlubricantspray-spraytheinsertioncordonly.

3.Thereisnovisibilityatalloraredblushonthemonitor

•Removethecamerafromthescope,sometimesthismaybeaproblemrelatedtothecameraandnotthebronchoscopeitself.

•Youmayhavecausedbleedingwiththeinsertioncord.

•Tryanotherbronchoscopeifavailable.

•Usenewbatteriesoranewlightsource.

Photo12

redblushimagecausedbybloodduringAFOI

Video4

useoftheBermanTMairway

4.Secretionsormucousobscuresvisibility

00:00/00:00

•Patientsshouldbegivenananti-sialogoguemedicationatleast15minutespriortoprocedure.Werecommendglycopyrrolate0.2-0.4mgivforadults.

•AttachO2at1-2L/minthroughtheworking/suctionportofscope.Thisworksbetterateliminatingandmobilisingsecretionsfromfieldofviewthansuctioningandhastheaddedbenefitofprovidingsomeoxygentoyourpatientduringtheprocedure.Wehavefoundsuctioningsecretionsinthissituationhighlyunsatisfactory.

•Insteadofrepeatedscopewithdrawal,wesuggestgentlyapproachingandbrushingthetipandthusthelensagainstmucosainthehypo-pharynx.Thiswillrapidlycleartheimage.

Photo13

secretionsandmucousobstructvisibility

5.Fieldofvisionappearstoosmall

•ForAFOI,chooseanadultfibre-opticscopediameterof5.0,5.1or5.2mm.Smallerflexibleopticalscopesareusuallyusedfornasalendoscopy,checkingdoublelumentubesandpaediatricpracticeandwillgiveyoua

reducedfieldofvision,inadequateornosuctionability,reduced•manipulationabilityanddifficultyin“rail-roading”antrachealtube(TT)duringtheprocedure.SmallerscopesarealsomorepronetodamagewhenusedforanAFO.

•Checkifthecameracanbezoomedinorout,thismay

•increasethefieldofvision

6.Imageblurredonmonitor

•Manycamerascanbefocussed:yourcameramaybeoutoffocus!

•Adjustthescopefocusbeforetheprocedurebyholdingthescopetiptwocmawayfromprintonawhitebackgroundwhilelookingintotheeye-pieceoronscreenandrotatingthescopefocusdial.Onceinfocus,theprintbeingviewedshouldbereadable.

7.Afterpassingthevocalcordswiththebronchoscopevisionisacutelylost.

•Thismaybeduetoseveralcauses,e.g.mucous,orpoornavigation.Haveyourunintoatumourblindly?Haveyoujustrunintothetrachealwall,againfailuretonavigate?

•Trytorestorevisibilityforexamplebymovingbackthescopealittle,donot

sedatethepatientatthispoint!

•Removethescopeanddonotadvanceitfurtherifthisistoleratedbythepatientandclinicallyfeasibleandcleanthelens.

•ConnectthecapnogramsamplinglinetotheworkingchannelofthescopebeforeremovingitandseeifyoucandetectCO2repeatedlyifvisibilitydoesnotimprove.

•Trytofeelthatthebronchoscopecannotbeadvancedfurtherorthattrachealringsareencountered.Dothisverygentlytopreventdamage.Thescopemayhaveenteredasmallbronchiallumen.Retractthescopecarefully.

BTechnicalproblems

8.YourDepartmentofAnaesthesiahasfinallyboughtabrandnewvideobronchoscopeandnobodyknowshowtooperateit

•Donotstartbeforeyouknowtheequipment,orsomebodyelseknowsexactlywhattodo.

•Askforanotherflexiblescopethatyouarefamiliarwith.

•Getanin-servicecontract.

9.Suctionisnotworking

•Mostcommon–suctionchannelblockedwithsecretion.Solution:highpressure(i/esmallsyringe)salinewashthrough.

•Thesuctiontubingmaybekinked,disconnectedorisleakingsomewhere.

•Alternatively,giveoxygenthroughtheworkingchannel1-2litres/mintocleartheairwayfrommucousorblood,thisworksmuchbetter.Donotusealargeoxygenflow10.

•Haveasecondseparatesuctionfromthesurgical“southside”andattachaYaunkersuctiontiptoit.

10.Lossoflightsource

•Thismaybeduetopowerfailure,atechnicalproblemoremptybatteries.

•Trytofindanotherbatterydrivenlightsource,suchasthelightsourcefromsurgicalcolleagues(laparoscopyequipment,headlightpowersourceetc).

•Useaflashlightandapplythelightdirectlytotheanteriorneckjustbelowthethyroidcartilage.

•Whenurgentintubationisrequired,insertalaryngoscopeorvideolaryngoscopeandusetheselightsourcestoguidethebronchoscope.

•Ifyouuseavideobronchoscopewithamonitorandmanycableconnections,makesureallthecorrectbuttonsareengagedandcablesattached.

CProblemswithadvancementofthetrachealtube

11.Thetrachealtubecannotpassthenoseaftertheinsertioncordoftheflexiblescopehassuccessfullypassedthevocalcords

•Useanasopharyngealairwaytodilatethenostrilcarefully.Thisreallyshouldideallybedonepriortoinsertingthescope.Trytoavoidthesurpriseof‘oops,nowthetubewon’tgothroughthenose‘11.

•Longitudinallycutanappropriatelysizednasopharyngealairway,lubricateitandinsertitintothenares.Passthescopethroughthesplitnasopharyngealairway(SNPA)andafterenteringthetrachea,pulltheSNPAoutandpeelitoffthescope.Thenthreadthetrachealtubeoffthescope.[photo14,seesplitSNPA]

•Useasecondbronchoscopethroughtheothernostrilifvocalcordsweredifficulttovisualizeandusetheotherflexiblescopeasaguide.

•Useasmallertube,insertthistubethroughthenosefirstandthenthescope,bewarenottocauseepistaxis.

Photo14

nasopharyngealairwayinsertedinleftnostrilandsplitnasopharyngealairway(SNPA)insertedinrightnostrilofmanikinwithinsertioncordofflexibleopticalscopeinsertedthroughSNPA.Techniqueused

atTheOttawaGeneralHospital,Ottawa,Canada

12.PoorcontroloftheETT,tubekeepsslippingdownscope

•Tapethetubeconnectortothebaseoftheflexiblescope[photo15]

Photo15

tubeconnectedtobaseofscope

13.Unabletomanoeuvretheendoscopetowardsthedesiredtarget–“won’tgowhereyouwantittogo”.

•Useaguidewireorhollowintubatingcatheter.12-14

•Useanupperairwayguidingdevice,forexampleaBermanTMoralaryngealmaskairway,asaconduitfortheflexiblescope

14.Scopestickingtotrachealtube

•Lubricatetheinsertioncordofthescopebeforeendoscopywithspray.

•DonotuseKYJellyTM,EMLATMcrèmeorthelike–thisdriestooquicklyandbecomessticky.

•Donotuseapetroleumbasedlubricantwhichmaydamagethescope.

•UseeithereyelubricationsuchasLacri-LubeTMoramedicalgradesiliconelubricantspray.

•Neverpushthescopeagainstresistancewhenit’swithinatube.Althoughitprobablywon’tharmthepatient,itwilldamagethescope.Stop,withdrawandlubricate.

Photo16

differentscopesizes

15.Thetubecannotbepassedthroughtheglottisafterintroductionofthebronchoscopethroughthevocalcords

•Normallythisiscausedbylaryngealimpingementonthearytenoidsortheepiglottis,whichcanbepreventedbyusingatubethatfitssnuglyaroundtheinsertioncordofthescope.

•Whenthetubecannotbeadvanced,turntheblueradioopaqueliningonthebacksideoftheETTfromthe“6-o’clockposition”intothe“1-o’clockposition”(clockwiseorcounterclockwiseisokay).Orrotatethetube360degrees.Inthismannerthebevelofthetubewillturnawayfromthearytenoids.

•Thismayalsobecausedbyimpingementofthebevelofthetubeontheanteriortrachealwall.Turningthebluelineofthetubefromthe6inthe“1o-clockposition”normallysolvesthisproblem.Theresearchhereandour

ownexperienceshowsthatbulletsiliconetiptubes,ortheintubatinglaryngealmaskairwaytubesorthe“birdbeaktubes”(ParkerTM)havesignificantlylesshangupatthelaryngeallevel.

Photo17

exampleofathinfibrescopeandarelativelylargetrachealtubewhichresultsinagapbetweeninsertioncordandtubethatmaycauselaryngealimpingementwhenthetubeisadvancedoverthe

scope

16.Tipoftheflexibleopticalscopecannotbeflexedbackbecauseofabreakinthesteeringcable

•Thisisararetechnicalcomplication.

•Removetubeandbronchoscopeasawholeanduseadifferentscope.

17.Thedistalinsulationrubberprotectionoftheinsertioncordiscurledupandmakesadvancementofthetrachealtubeverydifficult

•MakesurebeforeyoustartthattheETTisinspectedandnotdamaged.

•UsealargerdiameterETT.

•Useadifferentflexibleopticalscope.

•Ifyoucannotmovethescopeforwardorbackward,thescopeandtubeshouldbewithdrawnsimultaneously.

18.ThenasalRAE™tubeistoolongandthetipoftubealreadytouchesthenose,beforethetipoftheinsertioncordhaspassedthevocalcords

•Removetheconnectorofthetube,whichwillenablethetubetobeadvanced1.5cmhigheronbaseofthescope.

•Useasmallersizetube,whichnormallyisshorter.

•Shortenthelengthofthetubeandreinsertthetubeconnector.Onlydothisifnootheroptionisavailable,becauseyoumaybeholdpersonallyliableforinadvertentuseofamedicalproduct.

19.Thebronchoscopeisinadvertentlypassedthrough

theMurphy’seyeofthetube

•Trytoretractthescopeverycarefully;thismaybedifficultbecausethetipofthescopewillprobablybewedgedinbetweentheETTandtrachealwall.Ifthisisnotpossibleremovethescopeandthetubesimultaneously15.

Photo18

tipofflexibleopticalscopeOlympusTMLFTP,passedthroughMurphey’seyeofMallinkrodttube6.0

20.Aftercorrectintubationofthetracheawiththetipofthescope,thetubeinadvertentlypassesintotheoesophagus

•Alwaysadvancetheflexibleopticalscopefarenough,almostasfarasthecarina,topreventthisevent!

•Makesurethespacebetweenthetipoftheinsertioncordofthescopeandthetrachealtubeissmall,souseatightfittingtrachealtubethatfitssnuglyaroundtheinsertioncord.

•UseanAintreeintubatingcatheterTM[Photo19]

•Advancetheinsertioncordalmostasfarasthecarinaintothetrachea,beforerailroadingofthetube.

•Keepwatchingthecarinawhileadvancingthetube.

Photo19

flexibleopticalscopeOlympusTMLFGPinsertedinanAintreeTMAirwayCatheter

Video4

facetofaceAFOIwithtopicalisationusingaDeVilbissTM

00:00/00:00

21.Cannotadvancethetubeduringoralintubation

• UseaBermanTMorWilliamTMairwaytoguideintroductionoftheflexiblescope.Wheninsertedproperlythesedeviceswilllifttheepiglottisandbaseoftongue16.

• MakesureyouusethecorrectsizeBermanasitmaybetobigandguideyourscopedirectlyintotheoesophagus.

DProblemswithtopicalisationoftheupperairway

22.Thepatienthasalaryngealspasmafterintroductionofthescope.

• Thisisapotentiallifethreateningsituation.

• Stoptheprocedure,giveoxygenwithpositivepressureventilationandwaitseveralminutesbeforeyoumakeanotherattempt!

23.Inadequatetopicalisation

• TherearemanywaystotopicalisetheupperairwayofapatientforAFOThemostpopularoftheseare:nebulised(viaanebulisingHudsonTMmask),aerosolised(viaaMucosalAtomisingDevice(MADTM)oraDeVilbissTMtypeatomiser).Nerveblocks(blockingthesuperlaryngealblock)ortranstrachealinjectioncanalsobeused.Mostpatientsdonotappreciatenerveblocks.Thenebulisedandatomisedlidocainemodalitiesareshortacting.ItisimportanttostarttheAFOattheinstanttopicalisationhasfinishedandbythe10minutemarkthepatientshouldbeintubatedandasleep.Thattimeframeimpliesahighdegreeoforganisation(patient,equipment,theatrelogistics,staff,sedationtomentionafew)priortostartingtopicalisation.Ifforlocalanaesthesianasalgauzeswithcocaineortetracaineareused,moretimeisavailabletoperformtheprocedure.

24.Theairwayisnotanaesthetizedatallandistooreactive

• Itisdifficulttotopicalisemucosawhichiscoveredwithsecretions.Ensurethatananti-sialologueisadministeredfirst.

• Toomuchtimehasexpiredbetweenpatientpreparationandintubation.Trytotopicalizetheupperawayagain,orusethe“spray-as-you-go-technique”ortranstrachealinjectionoflidocaine17.Becarefulhere,donotgiveatoxicdoseoflocalanaesthetic18.Areasonabledoseforlidocainefortopicalisationis7-9mg/kg.

25.Thepatientexperiencesanacuteupperairwayobstructionaftertopicallidocainehasbeenapplied19.

• Thisisapotentiallifethreateningsituation,thecauseisnotcompletelyclear;itmaybeacombinationofareactiontothelidocaineandsevereupperairwaynarrowing.

• Intubatethetracheaimmediatelyorstoptheprocedure,removethescopeandgivesupportivetherapy.Ifnecessarydonothesitatetoperformacricothyroidotomy.

• Alwaysanaesthetizetheupperairwayinaroomwithaccesstoairwaymanagementequipmentandcardiovascularemergencymedication

• Ifapatientpresentswithaninspiratorystridor,beverycautiouswithtopicalisation,becausetheupperairwaydiametermaybeseverelynarrowed.

26.“Spray-as–you-go”(SAYGO)techniquenotadequate

• Ifyouusesuctionontheworkingchannel,stopsuctioning,thiswillsuctionthelidocaineintothesuctiontubingaswell.Thisisoftenforgotten.

• Uselidocainewithairinasyringe,notjustlidocaine,youwill“drown”yourpatientwithfluids.Bottomlineisthistotaldoseoftopicalisationneedstobe7-9mg/kg.Nomore!

• UseacommerciallyavailablealternativefortopicalizationduringSAYGOtoimprovethequalityofthelocalanalgesia.

27.Thepatienthasanknownallergytolidocaineyetstillrequirestopicalisationoftheupperairway

• Usealternativelocalanalgesiafortopicalanaesthesiae.g.cocainegauzesforthenoseanduseanintratrachealregionalblockwithmepivacaineorropivacaine2mg/mlifnotallergictothesemedications.

28.Almosttotalairwayocclusionoccursrepeatedlywhentheinsertioncordofthescopeispassedthroughtheglotticopening

• Removethescopeandtrytouse“sprayasyougo”forbetterupperairwayanalgesia.

• Useasmallerscope.

• Makesurethereisnotaverysevereairwaynarrowing,orunnoticedsubglotticobstruction.Ifthereisasubglotticobstruction,reconsideryourairwaymanagementtechnique.

• Youcoulduseavideolaryngoscopeincombinationwiththeflexiblescopeiftoleratedbythepatient:thisiscalledavideolaryngoscopyassistedflexibleopticalintubation(VAFOI)20.Itmaystillbeproblematictopassthevideolaryngoscopewiththeinsertioncord.

Photo20

Lidocainspray10%

Photo21

mucosalatomisationdevice

Photo22

XylometazolineHCLnosedrops

EBleedingproblems

29.Themucosaorintraoraltumourstartsbleedingafterintroductionofthescope

• Trynottotouchoral,nasalorpharyngealtissuewiththescope,alwaystrytopositionthescopeinthecentreoftheupperairway.Don’tinsertand/ormovethescopeforwardblindly.Alwayswatchthemonitorwhilemovingthescope.

• Useasuctionsystemthatisattachedtothescope.

• Alternativelyuseoxygenflowthroughtheworkingchanneltoblowawaythebloodandimproveyourvisualfield.

30.Epistaxisdirectlyafterintroductionoftheflexibleopticalscope

• Removethescopewheneverpossibleandattempttostopthebleedingandusetheothernostril.Preparethenosewithavasoconstrictor,forexampleoxymethazolinewhichisusedasadecongestor.

• Useanadaptednasopharyngealairway(seeSNPAandPhoto14)beforepassingthebronchoscopethroughthenosetopreventdamagetothenasalpassages11.

FOxygenationproblemsduringAFOI

31.PatientdesaturatesbeforeorshortlyafterthestartofAFOI

• GiveoxygenbyoxygenprongsormaskoutsidetheOR,whilepreparingtheequipmentorinterviewingthepatient.

• Give0,5-1liters/minoxygenthroughtheworkingchanneloftheflexiblescopeoruseafullfacemask.

• Stoptheprocedureandpre-oxygenatefor3minutesbymaskwith100%oxygen.

• Adaptimmediatelythesedation;ifonlyopioidsareused(recommended)makesuretocooperatewiththe(still)awakepatientbyaskinghim/hertobreathinandout(“commando-breathing!”)

• Useasmallcannula,f.e.14gaugeoraRavussinneedleTMthroughthecricothyroidmembranetogiveoxygen1-2liters/min,thiswillincreasesaturationtoasaferlevel.

GAnatomicalproblems

32.Alargesupraglotticmassortheepiglottispreventsagoodviewatthelaryngealinlet

•Trytopassaguidewirethroughtheworkingchannelandpassthisthroughthevocalcords.Advancethebronchoscopeovertheguidewirebeforethetubeisrailroaded.

•Trytousealaryngoscopeorvideolaryngoscopesimultaneouslytoenableintubationofthetracheawiththescope.

•Usetheawakefibrecapnicintubationtechnique12,13.

•Changepatientposition:patientheadup!

•Usegentlechinlifttoopenuptheairway,ormanipulatethetongue.

Photo23

anatomicalproblemsforintubation.TransversalCTscanoftheheadandneckofapatientwithalargebaseoftonguetumourwhichcrossesthemidline(betweenwhitearrows)andtrachealnarrowing

(yellowarrow)

33.Itisnotpossibletofindandidentifytheglottisduetoanatomicalabnormalities

•Consideranawakefibrecapnicintubation,ahollowsuctioncatheterisadvanceddeeplyintotheairwaytofindconsecutivecapnogramtracingandthiscathetercanbeusedasaguidewiretorailroadthebronchoscopeintothetrachea.12,13

•Askthepatienttotakeadeepbreath.Oftentimesyouwillnoticeairmovement(bubbles).

•DoaVAFOI:videolaryngoscopicassistedflexibleopticalintubation.Trytovisualizethelarynxwithavideolaryngoscopeandadvancethebronchoscopewithguidanceofthevideoimage20.Anepiglottismaybeseverelydistortedorevenmissingbecauseofpriorradiotherapy.

•Asanalternativeyoucoulddoaretrogradeguidewireflexibleintubation,theguidewireisadvancedretrogradelythroughtheglottisandtheguidewireispassedthroughtheworkingchannelofthebronchoscope21.

•Considertoinsertanintubatinglaryngealmaskairwayintheawakepatientaftertopicalisationandusetheitubatinglaryngealmaskairway(ILMA)asaguideforthebronchoscopetofindtheglottis22.

•AlwaysreconsiderifAFOIisreallythemostappropriatetechniqueforyourpatient.

Photo24

fibreopticscopewithfibrecapniccatheter

Video5

AFOIthroughILMA

00:00/00:00

34.Themouthopeningislessthan2.5centimetresandthenosecannotbeusedtointroducetheflexiblescope.

•Ifitisanticipatedthatmouthopeningwillbegreaterafterinductionofanaesthesia,useathinbronchoscopeandMLTtube,anduseageneralanaesthesiawithspontaneousbreathing.

•Consideranawaketracheotomyunderlocalanaesthesia.

•Considerretrogradebronchoscopyassistedintubation21.

35.Thelarynxisdeviatedanteriorly,whichmakesinsertionoftheflexiblescopepassedthevocalcordsimpossibledespiteagoodandclearview

•Advanceaguidewirethroughtheworkingchannelofthebronchoscopethatisusedtorailroadthescopeintothetrachea12,14.

•ChangetheapproachtoanasotrachealAFOIastheaxisofnasopharynxmayalignbetterwithananteriorlarynx.

36.Itisnotpossibleorcontra-indicatedtointubatethroughthenose

•PerformanoralawakeflexibleopticalintubationasmostoftheAFOIcanbedoneorally;consideranintubationaid,forexampleaBermanTMairway.

•IfanappropriatesizedBermanairwayTMorOvassapianairwayTMisnotavailableinsertanregularGuedeloralairwayasabiteblockandproceedwiththeAFOI,withtheinsertioncordnexttotheGuedel.Alternativelyuseadentalbiteblock.

37.Cannotgetintravenousaccess,buthavetodoanAFOI

•Getanotherpairofhands.

•Putinacentralline,ifneededwithultrasoundguidance,beforestartingtheAFOI.

38.Theairwaydiameterappearstobetoonarrowtoaccommodatetheinsertioncordoftheflexiblescope

•StoptheprocedureandtrytoreviewarecentCT-scanorMRIoftheheadandnecktoseeifthismaybecorrect.Useasupraglotticairwayordoatracheotomy.Sometimessupraglotticjetventilationisanalternativeinthissituation,howevertheriskatbarotraumaishigh.

•Useavideolaryngoscopetoestimateifairwaydiametermayindeedbetoonarrow.Sometimesitisverydifficulttotellifairwaydiametersaretoosmall,becauseoftheaugmentationorzoomofthecamera.

39.Itisimpossibletopassthebaseofthetonguewiththeflexiblescope

•UseagauzeandaMagillforcepstoprotrudethetongue.

•Useamandibularmanoeuvre,suchaschinlift,toliftthejaw.

•Useasuctiontube(YankaurTM)topullthetonguebyapplyingittothetipofthetongue;becarefulnottocausebleeding.

•Movethepatienttoanalmostsittingposition,gravitywillworktoyouradvantage.

HProblemswithsedation

40.Thepatientisunconscious

• Stoptheprocedureandallsedation.

• Givereversalmedication.

• Useonlyshortactingmedication,notmorethantwodifferentclassessimultaneously.Agoodcombinationinexperiencedhandsisremifentanilforanalgesiaandpropofolforsedationandamnesia,howeverthereisarelativelyhighincidenceofapnoeawhenusedincombination.Remifentanilaloneiswellpublishedandwellsupportedbuthasthedisadvantagethatisdoesnotcauseamnesia.IfyoustartpractisingAFOIitisprobablywisetostartsedationwithshortactingopioidsonlytopreventcomplicationswithsedation.

41.Thepatientbecomesapnoeicduringtheprocedure

• Askthepatienttotakeadeepbreathandinstructacolleagueoranaestheticnursetomonitorthepatient,usereversalmedicationorwaitandseeifthisispossibleandgivesupportivetherapy.Considerstoppingallsedativemedication.

IProblemswithpatientcooperation

42.Thepatientisaggressive

• Thisisacontra-indicationforanawakeprocedure.

• Trytounderstandtheproblem,reconsidertheneedforawakeintubation.

• Trymoresedationorsedatewithanotherclassofmedicationandaskforhelp.

• Consideramaskinductionusingvolatileanaesthetic.

43.ThepatientstartsvomitingduringAFOI

• Aspirationisnormallynotabigworry,becausethepatientstillhasmostorpartoftheirprotectivereflexes,however,visibilitywillprobablybepoor:stoptheprocedureandconsiderinsertingagastricdrainifatallpossibleorstartsanti-emetics.

• ConsideranAFOI“facetofacetechnique”withthepatientlyingontheside.

44.Thepatientissneezingcontinuouslyafterthenosehasbeenanaesthetizedwithlidocaine

• Stoptheprocedure,wait5minutesordoanoralfiberopticintubation.Wehaveseenthisphenomenonoccasionally.

45.ThepatientbitesontheinsertioncordduringoralAFOI

• UseaBermanTMintubatingairwayorabiteblocktopreventthisfromhappening.

46.Thepatientrefusesanawakeintubation

• ThisisacontraindicationforAFOI.PatientconsentisneededbeforeAFOIisperformed!

• Ifalreadystartedstoptheprocedureanddoanalternativetechnique.

• HaspropersedationbeentriedafterthepatientconsentstoAFOI?

JProblemswithflexibleopticalscopesincombinationwithanotherairwaydevice

47.Itisimpossibletopassthefiberscopethroughtheintubatinglaryngealmaskairway(FasttrachTM)

•Thisisprobablycausedbytheepiglottisliftingbar;ifpossibleinserttheILMAaneworusetheETTtoliftthebarandthenpassthescopebeyond.Thiswillprotectthescope.

•Trytomanoeuvrewiththetipofthebronchoscopeunderneaththeepiglottisliftingbar.

•Performthe“Chandymanoeuvre”,thiswillprobablyalignthedevicewiththeglotticopeningtoenablepassageoftheflexiblescope.Foradescriptionofthismanoeuvrewerefertotheoriginalarticle23.

48.ItisimpossibletoadvancetheETTthroughalaryngealmaskairway

•Makesurethetubefitsthroughthelaryngealmaskfirstduringpreparation.

•RemovethebarswithapairofscissorspriortoinsertionoftheLMA,oruseasupraglotticdevicewithoutbars.Makesuretherearenosharpedgesthatcandamagetheupperairway.

•Thismaybeproblematicinsomepediatriccasesorinsmallpeople.AlwaystrybeforestartingtoensurethattheETTandlaryngealmaskarecompatible.

Photo25

laryngealmaskairway3.0,paediatrictube4.5,OlympusTMDPfibrescopepreparedforpaediatricintubation

Photo26

thyroidtumorwithmassiveneckenlargement

Photo27

swellingfloorofthemouthbecauseofallergicreaction

Photo28

glotticandsupraglotticneoplasmleftvocalcordpretreatment

Photo29

glotticandsupraglotticneoplasmleftvocalcordpostlasertreatment

Photo30

intubationthroughILMA

48.ItisimpossibletoadvancetheETTthroughalaryngealmaskairway

•Makesurethetubefitsthroughthelaryngealmaskfirstduringpreparation.

•RemovethebarswithapairofscissorspriortoinsertionoftheLMA,oruseasupraglotticdevicewithoutbars.Makesuretherearenosharpedgesthatcandamagetheupperairway.

•Thismaybeproblematicinsomepediatriccasesorinsmallpeople.AlwaystrybeforestartingtoensurethattheETTandlaryngealmaskarecompatible.

Video5

AFOI throughLMA

00:00/00:00

Video6

AFOIthroughIgel

49.ThetrachealtubecanpasstheLMAbutisnotlongenoughtobeabletowithdrawtheLMAsafely

•PutinanAintreeTMcatheterfirst,removetheLMAandthenadvancethetrachealtubeovertheAintreeTMairwaycatheterTM

50.Yourplanistoperformanoralflexibleintubationbutoralairwayisnotavailableinthecorrectsize

00:00/00:00

•Useabiteblockornormaloropharyngealairwaynexttotheinsertioncordinsteadofthemoreoptimaldevices.

•Usegentlechin-lift,jaw-thrustmanoeuvreswithanoralbiteblockornormaloropharyngealairwayinsitutopreventthepatientfromdamagingthescopewiththeteeth.

KVentilationoroxygenationproblemsaftertrachealintubation

51.Aftervisualcorrectplacementofthetubeitisnotpossibletoventilatethepatient

• Doacarefulinspectionofthetrachea.ArethereanyobstructionsbelowthelevelofthetipoftheETT?Lookfortrachealstenosis,orairwaytumours.

• Alsoconsideraseverebronchspasm!

• Isthetubereallystillinthetrachea?Ifitisnotpossibletodisplayconsecutivecapnogramsitishighlylikelythatthetubeisnotinthetrachea.

52.AfterintubationwithanMLTtubeitisnotpossibletoreconnecttheconnectoradapter

• UseaMagillforcepstopushbackthetubeandholditinplaceduringwhichtheconnectorisreconnected.

• DonotdisconnecttheadapterbeforeyoudoanAFOI.Thisisnotnecessarywhenapropersizeflexibleopticalscopeisused.Sometimesitisnecessarywhenavideoscopeisusedbecausethecomputerchipispositionedinthetip,whichincreasesthediameteroftheinsertioncord.

53.AfterAFOIandtheuseofaRAEnasaltube,thetubeiskinkedduringventilation

• WhenusingaRAEnasaltubearoundabronchoscope,thesitewherethetubeisbent,tostraightenthetubewhenitisattachedtotheflexiblescopebecomesaweakspot.TrytostabilizethissitewithtapeorbetteruseaMLTtubeifthesurgeonsconcur.

54.Aftervisualguidedflexibleintubationofthetracheaitisnotpossibletodisplayacapnogramonthemonitor

• Firstensureyouareabletoventilatethepatient.Ifunable,your“can’tventilatesequenceorroutine”shouldbeenactedimmediately.

• Clearthecapnographtubingfromfluidsormucous.

• Insufflatemoreairinthepilotballoonofthetubecuff.

• ThetubemayhavebecomeblockedwithmucousormatterafterretractionofthebronchoscopeandadvancementoftheTT.Introducethebronchoscopeagainandcheckforanyobstruction.Tubeobstructionbyintranasalpolypsorpiecesofnasalconchaeafterintubationhavebeendescribed.

• Thecuffofthetubemayhavebeendamagedafterpassagethroughthenose.Arethereanysignsofcuffrupture(forexampleairleakage)?ExchangethetubeoveranTTexchangecatheter.

• Itispossiblethatthetubehascausedafalse-routeorruptureofthetracheal

wallorandhasendedupintheoesophagusormediastinum.Performacarefulinspectionwiththebronchoscope.

LLogisticproblems

55.IcannotstandbehindthepatientbecauseIamtooshort

• Useabenchtostandhigher,lowertheoperatingtable.Trytoprepareyourprocedureascomfortableaspossible.

• Doa“face-to-facetechnique”,eitherinthesittingpositionorwiththepatientlyingontheirside.Rememberthatthiswillaffecttheorientationoftheimagesthataredisplayed.Thesearenotdisplayedinthewayyouareusedto.Youwillfindtheepiglottisinthelowerfieldofview.

56.Theheadandnecksurgeonhasnotyetarrivedatthehospitalandthepatientwithananticipateddifficultairwayneedstobeintubatedurgently

• PrepareforanemergencycricothyroidotomyasaplanBorCandstarttheawakeintubationprocedure.Notonlypalpatebutalsomarkthecricothyreoidmembraneontheskinofthepatientwithamarker,soyouknowwheretogoinanemergency.Rememberproperpositioningofthepatientforthisprocedure.

• Consideratrans-cricoidcannulasecuredinplacebeforeyoustarttheAFOI(withanoxygenflownogreaterthan1-2l/min).Thiswilloxygenatethe

patientandyoucouldusethiscatheterasalandmarktoidentifythetracheaunderlowvisibilityconditions.

57.DuringtheAFOIyourpresenceisurgentlyrequiredatanothersideofthehospital

• Ifpossibleaborttheprocedure.Ifinarush,chancesoffailureincreasedramatically.

• Onepatientatatimeandyourresponsibilityiswiththecurrentpatient.However,anAFOIcanbedonewithin30seconds,soifyouareexperiencedjustfinishtheprocedure.

58.TherearenotenoughpatientsinmysurgicalpopulationtopracticeAFOIroutinely

• Tryvirtualflexibleopticalteachingtasktrainers.

• ConsidertrainingonDexterTM(ReplicantMedicalSimulators,NewZealand)fordexterity.Ithasscientificallybeenproventhatflexibleopticalscopehandlingisgreatlyimprovedbytrainingacoupleofhoursonthisnonanatomicaldevice8

• Doasmanyflexibleintubationsinpatientsundergeneralanaesthesiaviatheoralroute.

59.DuringtheadvancementprocedureofthetubethroughtheglottisduringAFOIitisnotedthatsomebodyhasforgottentoputanETTaroundtheflexibleopticalscope

• Startagain.Neverstartwithoutcheckingalltheequipment.Neverinducegeneralanaesthesiabeforecorrecttrachealtubeplacementhasbeenconfirmed.Remember:thisprocedureiscalledAFOI(intubation)andnotjustbronchoscopy.

• DoachecklistbeforethestartoftheAFOI.(Seefig.3).

MExtubationproblems

60.TheAFOIwasverydifficultanditisnotclearifextubationissafe

Therearegenerallythreesafeoptions:

• Useanairwayexchangecatheter(f.e.CookairwayexchangecatheterTM)andleavethiscatheterinthetracheaafterextubation.Mostpatientswilltoleratethiscatheter.

• PostponeextubationandbringthepatientpostoperativelytoPACUorICU.

• Askyoursurgicalcolleaguestoperformasurgicalairwaybeforeextubatingtoprotecttheairway24,25.

Discussion

ThegoldstandardforthemanagementoftheexpecteddifficultairwayisconsideredanAFOIintheawakepatient26,27.Thefactthatthepatientisawakeisbothasignificantadvantageandapotentialdraw-back.Tomakethingscomplicated,thepatientisdoingallthethingshenormallydoes:breathing,movingswallowing,sneezing,andtalking.Thequestionis:whyisatechniquethatisconsideredthegoldstandardnotuniversallyusedevenwhenclearlyindicated?Oneoftheanswers:maintenanceoftheskillsthatarenecessarytomasterthistechniqueistoochallengingtomasteriftrainingorclinicalpracticeislimited,orinsufficientwhich,sadly,isinmanycountriesworldwidethenormratherthantheexceptiontotherule.AFOIcanbeconsideredasahighlycomplextaskthatrequiressoundtechnicalandmedicalknowledge,dexterity,goodcommunicationskills,leadershipandtheabilitytoworkunderpressure.IntheidealworldeveryanaestheticunitshouldhavepersonnelthatcanconfidentlyperformanAFOI.

Ininexperiencedhands,AFOIisoftenperformedwitholdequipmentunderstressfulconditionswhichisnotagoodformulaforsuccess.Indeed,AFOImaycertainlybeveryeasyifupperairwayanatomyisnormal,thepatientiscooperativeandupperairwayanalgesiaisgood.However,oftenanAFOIwillbeaccompaniedbyvariouschallenges.ForthesereasonsanaesthesiologistssometimestrytoavoidperforminganAFOIalthoughclearlyindicated.

AbriefwordonthepsychologyofAFOI

AFOIcanbeanextremelythreateningandinvasiveprocedurefromthepatient’spointofview.Nothavingthepatient’sconfidencefromthefirstmeetingtotheprocedureitselfwillresultinpoorconditionsfortheendoscopist,abadexperienceforthepatientandthetheatrestaffandfuture

reluctanceofbothpartiestorepeatthisprocedure,howeverclinicallyindicated.Keyistoengagethepatientsfromthefirstmoment,gaintheirconfidence,reassureatalltimesandneverlosecontactwiththemuntiltheyareasleep.Contactespeciallyduringtheproceduremustbemaintainedbysilencingtheunnecessarynoiseandchatterinthetheatreandfocusingyourpatientonyourvoice.Duringtheprocedurethevoiceoftheprimaryendoscopistsmustnotonlybetheonlyaudiblevoicebutmustalsoneverfallsilent.It’sinthesilencethatthepatientsmindisallowedtobuilddemonsorworstcasescenariosandtheendoscopists’risksrapidlylosingthepatient’scooperation.Thecontentoftheendoscopists“chatter”duringtheprocedureisnotthatcritical.Theoverallgoalistocalmandcomfortthepatient,tocomplimenthimoncooperatingandlastbutnotleasttoestimatethelevelofsedation.Itiscriticalthattheendoscopistschattertothepatientduringtheprocedure,whilethescopeisinthepatientsairway,isnotconstructedinsuchawaythatthepatientfeelstheneedtotalkbackoranswer–thiswilldynamicallychangetheairwaygeometry,causelossofviewandaddtimepluscomplexitytotheprocedure.Questionssuchas“howyoudoing?”withascopeintheairway,areneitherhelpfulnorproductive.

Sedationisacomplexarea.TheintentofsedationforAFOIistoincreasepatientcomfortandprovidesomedegreeofamnesia.Changeofsensoriumissometimestobediscouragedespeciallywiththepotentiallythreatenedairway.Rapidlyreversibledrugsarefarpreferableoverthosethatdonotprovidethe“getoutofjail”option.Havingtriedmostoptionsformanyyearsincluding(Fentanyl,Midazolam,FentanylandMidazolam,PropofolTCI,PropofolandFentanyl,Dexmedetomidine),wehavefoundthemtobemostlyunsatisfactorybecausetheonsettimeofthedrugsisnotfastenoughwhenasomewhatdeeperlevelofsedationisrequiredduringtheintroductionoftheETTthroughthenoseorglottis.Patientsaregenerallyover-sedatedandoccasionallyinadequatelysedated.Theover-sedatedpatientsdonotreversetheirlevelofsedationquicklyenoughtomakeanyofthesedrugsreallysafeinthissetting.ThedrugwhichforuscomesclosesttoourneedsforthissettingisRemifentanil.Anadvantageousside-effectofRemifentanilinthissetting,aswithallopiates,itthatitisanantitussive.Evenathigherlevelsandshouldthepatientbecomeoversedated,theyremainvoiceresponsiveandtheinfusioncanthenbereducedorstoppedwithrapidreturntopre-sedationsensorium.RememberthatRemifentanilalonedoesnotprovideamnesiafortheprocedure,aside-effectthatissometimesbeneficial,forexampleduringprolongedanddifficultintubationprocedures.We

recommendadultRemifentanilinfusiondosesof0.07–0.1micrograms/kg/min.Thesingleuseofremifentanilisprobablythebestsupporteddrugforthispurposeintheliterature,howeveritisnotwithinthescopeofthisarticletodiscussallthedrugs28,29Thedosageofremifentanilneedstobereducedfortheelderlyorthesystemicallyunwellpatient.InsurethattheRemifentanilinfusionislowconcentration–say20microgramspermlina50mlsyringe.Withthisconcentrationtherewillbeamoreconstantdrugdeliveryfromthesyringedriver.StarttheRemifentanilinfusion5minutesbeforetheactualendoscopy.Remifentanilcanbeadministeredincombinationwithpropofolinexperiencedhands,bothgivenasinfusion.Thesedrugsareshortactingorrapidlyreversibleandgivegoodanalgesia,sedationandamnesia.Howeverthereis,asstatedprevious,arelativelyhighincidenceofapnoeawhenusedincombination.AFOIseemsformanyclinicianstobeaverycomplextask.Itisverydifficulttosimultaneouslywatchamovingtargetthroughaflexiblescope,monitorandtalktoapatientandsedatehimaswellandcoachalltheotherpeopleintheatrewhoratherwouldimmediatelystarttheirsurgicallist.Whydon’twethen,forexample,performanAFOIwithtwoanaesthetistsasaroutinewheneverfeasible?Thisisnotcommonpracticeinmanyhospitals.OnlyafewofusaresuchskilledtechniciansandcommunicatorsthattheycandoanAFOIconfidentlyalone.Howmanyofusworkingatgeneralhospitalsperformmorethan5AFOIayear?Andhowmanyofustakeregulartrainingsessionsinafull-scalemedicalsimulatortoretaintheskillorrecertify?

Photo31

Dexteritytrainer

Photo32

Dexteritytrainercomponentsforscopetraining

Photo33

ORSIMTMmedicalsimulator

Conclusions

Inconclusion,donotlettheseincidentsdiscourageyoufromdoinganAFOIorspoilyourAFOIexperience.Mostincidentsorcomplicationsarepreventable.Whydon’tyoutrytobecomeoneofthedoctorswhocanperformanawakeflexibleintubationconfidently?Asdescribedinthisbook,foralmostallproblemsthereisasolutionandmostproblemscanbeprevented.

Finally,andthismaybeaveryhumblingexperience,donotforgetthatsomepatientscannotbeintubated,notevenbytheworld’sbestairwaymanagers.Rememberoxygenationwillsaveapatient’slife,notintubation.

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