Awake Fibreoptic Intubation Course
Date:
Wednesday
Time:
08.00 – 13.00 Meet in Anaesthetic Trainees
Coffee Room – 3rd Floor Maples Link Corridor
By Theatres
Venue:
3rd Floor Podium
UCH
Course Organisers
Dr Simon Clarke
Consultant Anaesthetist UCH
Dr Damon Kamming
Consultant Anaesthetist UCH
Dr Raman Verma
Consultant Anaesthetist UCH
1
We advise that you must not be on call the
night following the course
Programme
Please remain NBM (solids) from 6.00 a.m. –
(water up until 08.00 a.m.)--and bring this booklet
and signed consent form with you to the course.
08.30 – 09.00
Introduction
Calculate dose, draw up drugs
09.00 – 09.30
Dr Ian Calder’s Video
UCH AFOI DVD
Handling the scope
09.30 – 10.00
Mannequin Practice
Topical Anaesthesia Method
10.00 – 10.45
Practice candidate no.1
10.45 – 11.30
Practice candidate no.2
11.30 – 12.15
Practice candidate no.3
12.15 – 12.45
Q & A, Closure
2
Airway Endoscopy Under Local Anaesthetic
Before volunteering for an awake fibreoptic endoscopy you will need to
understand what is involved, the risks of the procedure and exactly how you
can expect to feel during and afterwards.
Method
The procedure takes place in an operating theatre with full resuscitation
facilities available.
Each delegate will have fasted for at least four hours prior to being
endoscoped. To this end, please ensure that you have had a light
breakfast (and/or are well hydrated) prior to 6.00 a.m. on the morning of
the course (not necessarily starved from midnight the previous night).
Routine monitoring is established (ECG, NIBP, and pulse oximetry). Topical
co-phenylcaine spray (via an atomiser device-MAD) is applied to both nostrils.
A 20/22g cannula is inserted into the dorsum of the hand or the antecubital
fossa and glycopyrrolate 4 micrograms/kg is given intravenously. Oxygen will
be administered, followed by the topical application of lidocaine (fine spray
throughout the airway via atomiser & the fibreoptic scope). When satisfactory
anaesthesia has been achieved, course members will perform airway
endoscopy under direct supervision. Each delegate will perform airway
anaesthesia and the endoscopy procedure on the other 2 delegates in turn.
Pulse, BP and Sa02 will be monitored at frequent intervals during the
procedure. Local anaesthetic injections, cocaine or sedation will NOT be used.
Risks
Trauma to the airway including bleeding or perforation and abscess formation
Allergic reactions to lidocaine, glycopyrrolate, co-phenylcaine, preservatives in
local anaesthetic solution, latex etc.
Hypertensive response with co-phenylcaine
Drug toxicity due to lidocaine
Aspiration of gastric contents
Infection: localised or systemic
With the exception of minor nasopharyngeal trauma, none of these
complications are seen commonly. Doses of lidocaine applied to the airway
are large (up to 9mg/Kg). These have been found to be acceptable in-patients
undergoing bronchoscopy (Efthimiou J, Higenbottam T, Holt D, Cochrane GM.
Plasma concentrations of lidocaine during fibreoptic bronchoscopy. Thorax
1982; 37: 68-71). Awake fibreoptic intubation has been reported to be safe in
patients at high risk of aspiration (Ovassapian A, Krejcie TC, Yelich SJ, Dykes
MHM. Awake fibreoptic intubation in patients at high risk of aspiration. Br J
Anaesth 1989; 62: 13-16).
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How Does it Feel?
There is obviously a degree of apprehension associated with anticipation of an
awake intubation. It is advisable to ensure an empty bladder as the whole
procedure may take up to an hour.
You will be settled in the supine position with head elevated on an operating
table and monitoring will be applied - NIBP, ECG and pulse oximetry. A small
cannula will be inserted into the back of your hand or the antecubital fossa.
Early preparation includes the application of a vasoconstrictor to the nose; this
is a little uncomfortable and sometimes makes the eyes water.
This is followed by the IV administration of Glycopyrrolate 4mcg/kg. Over the
following ten minutes the glycopyrrolate will produce a dry mouth. Topical
application of local anaesthetic spray to the airway tastes unpleasant.
Lidocaine has a bitter taste and may produce coughing or gagging. Too early
advancement of the scope, before adequate anaesthesia, may also cause
coughing etc.
When the larynx ceases to react to further increments of local anaesthetic the
fibreoptic scope will be passed through the cords. In general the procedure is
well tolerated. The position of the scope is confirmed & then removed.
You may feel a certain degree of elation when the procedure is over. This
sensation is enhanced by the effects of lidocaine which produces some
dysphoria. Following the procedure the subject will be aware of a dry mouth
and of nasal stuffiness. When oro-pharyngeal sensation returns to normal we
recommend a warm cold-cure drink containing paracetamol to deal with the
nasal and throat discomfort. Both usually settle after 12 to 14 hours. Other
useful things to have available are a Lipsyl stick for the dry mouth and some
Vicks vaporub, which eases nasal stuffiness overnight.
Clearly in a course of this kind, it is essential that we exercise the utmost
caution. For this reason we are explicit about the risks and some candidates
may be refused entry as participants.
Participating candidates must not drive for 4 hours after endoscopy. We
also advise that you must not be on call immediately following the
course.
We would be grateful if you could fill out the feedback form (at the end of the
booklet) after the course and telephone or email us the following day to let us
know how you are feeling and if you had any problems overnight.
4
Equipment
Fully operational scope/ TV monitor- set up & checked
Monitoring equipment / Resuscitation facilities, Assistant.
Suction apparatus
Oxygen supply; Face mask/ nasal sponge, green tubing
Different type/size ETT’s (6.0, 6.5 flexible reinforced ETT’s)
Split oral airway (Berman)
IV cannula, Glycopyrrolate 4mcg/kg, Co-phenylcaine 2.5mls
Laryngo-Tracheal Mucosal Atomisation Device (MAD)
Epidural Catheter 16 G (with tip cut off)
2% lidocaine gel (“Instillagel”) 5ml to mouth to gargle
1% lidocaine 10ml via MAD over back of tongue directed to larynx
4% lidocaine 2ml x 3 (in 5ml syringe with 2ml air)
Warm sterile saline (to soften tube), KY Jelly (nose)
Saline (lubrication for railroading tube over scope – not performed
on course!)
Additional Equipment etc: Oral airway devices, Berman oral airway size 8 & 9, bite blocks,
laryngoscopes, LMA’s, naso-pharyngeal airways
Sedation/analgesia- midazolam 1mg/ml, fentanyl 10ucg/ml,
propofol 10ml/hr (not performed on course)
Gloves, Tissues
Platform to stand on!
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Local anaesthesia for awake fibreoptic intubation
Maximum Dose of Lidocaine (9mg/kg)
Calculate personal dose according to weight
Average 60kg woman = 540mg
Average 70kg man = 630mg
2ml syringe – 1-1.5ml co-phenylcaine
(50mg/ml lidocaine, 5mg/ml phenyephrine)
75mg
2ml syringe – 1-2ml glycopyrolate (4mcg/kg)
10ml Instillagel syringe – 10ml 2% lidocaine
200mg
10ml syringe – 1% lidocaine
100mg
5ml syringe x 2 – 2ml 4% lidocaine and 2ml air
160mg
Total lidocaine dose
535mg
Use mucosal atomising device (MAD) for all airway anaesthesia excluding
Instillagel
Airway anaesthesia
3 Targets
3 Nerves
1. Nose and anterior tongue
Trigeminal
2. Oropharynx, posterior tongue and gag
Glossopharyngeal
3. Larynx.
Vagus
(Supraglottic - Superior laryngeal nerve)
(Infraglottic - Recurrent laryngeal nerve)
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Ten Step Technique
1. Standard monitoring and intravenous access
2. Intravenous glycopyrolate according to weight
3. Intranasal co-phenylcaine 1 - 1.5mls to best nostril with MAD
4. Intranasal instillagel 2 - 3 ml to sniff
5. Intraoral instillagel 5ml to gargle for 1 minute then suction and test gag
6. Intraoral 1% lidocaine. 10 ml sprayed toward larynx with MAD with
tongue extruded and patient mouth breathing and ‘panting’
7. Spray as you go via epidural catheter with 2ml increments of 4%
lidocaine directly onto cords under direct vision with the scope
8. Spray as you go via epidural catheter with 2ml of 4% lidocaine
through cords onto tracheal mucosa under direct vision with scope if
planning to railroad endotracheal tube
9. If attempting awake oral and gag a problem despite above measures
then optional extra intraoral 10% lidocaine spray to each side of
oropharynx.
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Consent to Endoscopy +/- Intubation under
Local Anaesthesia
As a voluntary participant on this course, this will involve
undergoing fibreoptic nasotracheal & orotracheal endoscopy,
and possibly naso/orotracheal intubation under local
anaesthetic.
There may be some discomfort, namely nasal & airway
irritation during the procedure, which causes coughing, and a
dry mouth & nasal stuffiness afterwards, lasting several
hours. Candidates will have fasted for at least 4 hours prior
to the procedure and are advised to fast for approx. 2 hours
post procedure and not to drive for 4 hours afterwards.
Risks to be aware of include: Trauma to the airway including bleeding or perforation
Allergic reactions to lidocaine, glycopyrolate, xylometazoline or
preservatives in local anaesthetic solutions
Hypertensive response with phenylephrine
Drug toxicity due to lidocaine
Aspiration of gastric contents
Infection; localised or systemic
Consent:
I wish to take part in this endoscopy airway training course. In doing
so, I am willing to act as a subject for endoscopy +/- intubation
under local anaesthesia. I have fasted as per recommendations. I
am also aware of the side effects of the procedure and the possible
risks/complications of the procedure listed above.
Name (Print)……………………………………………
Signature ……………………Date …………………
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AFOI Feedback Form
1. What was your overall impression of the course? (Circle one)
Very poor / Poor / Fair / Good / Excellent
2. How did you find the experience of endoscopy on yourself? (Circle
one)
Very distressing / Distressing / Acceptable / Enjoyable / Very enjoyable
3. What, if any, aspects of the endoscopy did you find unpleasant?
Pain / Anxiety / Coughing & Gagging / Other sensation (please specify)
a. At what stage did they occur?
4. Did you feel that you experienced any of the recognized side-effects
of local anaesthetic drugs?
Yes / No
a. If Yes, please specify symptoms
b. At what stage did they occur?
c. How were they resolved and was this adequate?
5. Do you feel you have achieved the aims set out at the beginning of the
course?
Yes / No
6. Would you feel confident about performing an awake fibreoptic
intubation on a patient?
Yes / No
7. Would you recommend this course to a colleague?
Yes / No
a. If yes, why?
b. If no, why not?
8. How do you think the course could be improved?
9. Any other comments?
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