These awake or ketamine facilitated intubations were less than 1% of the total. I don't think anyone is really good at this. I've certainly made my mistakes. I had a patient with airway angioedema from hereditary angioedema. I performed nasopharyngoscopy and it looked like I had a clear shot to intubate him. I decided just to RSI with a double set up (mistake). Once I laid him down, I couldn't see anything. There was edema everywhere obstructing my view. I looked with video and direct. I was preparing to cric and gave one shot with a bougie. Luckily, I guessed where the cords were and it went in.
The lesson I learned from this case is that the view with the patient upright is much better than lying down for an impending airway obstruction. If I had a do over, I would have kept the patient upright and tried an awake intubation first. Some go through the nose and some through the mouth. I did find the comments interesting about using the hyperangulated video laryngoscope to go through the mouth. This seems easier than trying to shove an ET tube over a scope. Pushing the tube through the nose is also difficult--but the view is better and more stable. I would also like to see some best practice regarding topical or local anesthesia. I like topical application above the cords. I would also probably add a translaryngeal block. I would add some anesthesia over the cricothyroid membrane to help with later cric if needed.
Luckily, this is a rare procedure. Which is also why it's so difficult to perform.
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Dallas H. - November 8, 2021 12:18 PM
I had an attending who insisted on etomidate only intubation. It was always unpleasant.
Byron F. - November 11, 2021 5:40 AM
why did they not give a brief description of topical anesthesia,,,nebulized lidocaine? other? how much?
Nathan M. - November 21, 2021 5:05 AM
These awake or ketamine facilitated intubations were less than 1% of the total. I don't think anyone is really good at this. I've certainly made my mistakes. I had a patient with airway angioedema from hereditary angioedema. I performed nasopharyngoscopy and it looked like I had a clear shot to intubate him. I decided just to RSI with a double set up (mistake). Once I laid him down, I couldn't see anything. There was edema everywhere obstructing my view. I looked with video and direct. I was preparing to cric and gave one shot with a bougie. Luckily, I guessed where the cords were and it went in.
The lesson I learned from this case is that the view with the patient upright is much better than lying down for an impending airway obstruction. If I had a do over, I would have kept the patient upright and tried an awake intubation first. Some go through the nose and some through the mouth. I did find the comments interesting about using the hyperangulated video laryngoscope to go through the mouth. This seems easier than trying to shove an ET tube over a scope. Pushing the tube through the nose is also difficult--but the view is better and more stable. I would also like to see some best practice regarding topical or local anesthesia. I like topical application above the cords. I would also probably add a translaryngeal block. I would add some anesthesia over the cricothyroid membrane to help with later cric if needed.
Luckily, this is a rare procedure. Which is also why it's so difficult to perform.