Awake Fiberoptic Intubation Outside the Operating Room: Lidocaine Awake Fiberoptic Intubation Outside the Operating Room: Lidocaine “Rinse and Swish” Technique “Rinse and Swish” Technique

R. F. Ghaly, MD, FACS, J. J. Rivera-Meléndez, MD, R. S. Childs, MD, K. D. Candido, MD, N. N. Knezevic, MD, PhD

Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA

DiscussionAbstract

References

Introduction Procedure

A 74-year-old female with severe diffuse contractures was admitted to the emergency department with dyspnea. The anesthesia service was called for emergent intubation in an anticipated difficult airway. Awake fiberoptic intubation outside the operating room was done with minimal equipment and steps without the use of nerve blocks. Lidocaine 1% solution was allowed to rinse and swish the oropharyngeal region repeatedly. The patient was asked not to swallow and encouraged to cough during the rinse. The fiberoptic scope passed smoothly through the glottic opening, and the tube was inserted and secured in place promptly. This case report demonstrates that awake fiberoptic intubation is a simple and feasible technique that can be performed outside the comfort of the OR in an emergency setting.

• Awake fiberoptic intubation is a known technique applied for difficult intubation or unstable cervical spine. • It is usually performed in the operating room where equipment is readily available. • Outside the operating room, the knowledge is lacking about the feasibility of the technique. • There are many obstacles to performing awake fiberoptic intubation outside the operating room. These include the lack of essential equipment, resources, and familiarity with the technique. • In this case report, the authors present a fiberoptic technique simple and feasible in an environment outside the operating room.

• Difficult airway and intubation were anticipated.• Our set-up included ASA monitors, oxygenation, proper support to head, fiberoptic bronchoscope with battery light source, suction, lidocaine 1% solution and, sedation. Back-up plans were available. • Ensuring adequate oxygenation, minimal sedation with 2 mg midazolam was administered. Then some benzocaine oral spray followed by lidocaine 1% solution were used to topicalize the orophayngeal region. • Lidocaine was provided through a syringe and allowed to rinse and swish repeatedly. • The patient was asked not to swallow and encouraged to cough. • The tongue was allowed to move in all directions to help deliver the lidocaine to the posterior third of the tongue to abolish the gag reflex. Frequent suction was done to assist. • After 4 minutes, an Ovassapian airway was placed. A well lubricated fiberoptic bronchoscope loaded with a regular size 7.0mm endotracheal tube was passed.• After visualization of the epiglottis and vocal cords, the scope passed smoothly through the glottic opening. • There was no discomfort as the scope and the tube were passing. The tube was inserted and secured in place ensuring prompt access to the airway.

• The patient was appropriately identified as an anticipated difficult intubation given her severe contractures and inability to lay supine.• A technique allowing the patient to be promptly intubated while in a sitting position and minimizing airway trauma was deemed preferable. In this case it was awake fiberoptic intubation.• The anesthesiologist should be well trained in fiberoptic intubation. It prevents unnecessary airway trauma due to multiple failed attempts and the result of non-visible airway. • Outside the operating room, fiberoptic intubation may seem challenging due to lack of resources and equipment. • A simple 1% lidocaine “rinse and swish” allowing the patient to cough but not to swallow may suffice in a good number of patients to perform smooth fiberoptic intubation. • There was no need for deep sedation, injection of local anesthetics for nerve block, or excessive use of benzocaine.

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• A 74 years old female with history of Louie body dementia, advanced Parkinson’s disease, psychosis, depression, anxiety, UTI, sacral decubitus ulcers, anemia, severe diffuse contractures with inability to communicate or care for herself was transferred from her nursing home with dyspnea. • In the Emergency Department, the patient was febrile, tachycardic, and tachypneic.• She was placed on BIPAP but continued to show signs of respiratory distress with low oxygen saturation. • Emergency Department personnel anticipated a difficult intubation due to her severe contractures and her inability to lay flat. • Anesthesia service was called for emergency airway management.

Case Description