Preparation of the Patient for Awake Intubation

Sanchez, Antonio; Iyer, Raj R.; Morrison, Debra E.

doi:10.1016/b978-032302233-0.50016-0

Cited by 13 publications

(13 citation statements)

References 85 publications

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“…This study demonstrates that topicalisation of the airway using atomised lidocaine allows awake fibreoptic intubation in the morbidly obese and we found this to be an effective, rapid, and safe technique. Although airway topicalisation using atomised local anaesthetic has been described previously [9, 10], its assessment in the morbidly obese population has not been reported. In addition, as far as we are aware, this is the first report of the plasma lidocaine levels produced using this technique.…”

Section: Discussionmentioning

confidence: 99%

Airway topicalisation in morbidly obese patients using atomised lidocaine: 2% compared with 4%*

Wieczorek¹,

Schricker²,

Vinet

et al. 2007

Anaesthesia

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SummaryWe evaluated the technique of airway anaesthesia using atomised lidocaine for awake oral fibreoptic intubation in morbidly obese patients using two doses of local anaesthetic. Morbidly obese patients were allocated to receive either 2% or 4% lidocaine (40 ml) for oral airway anaesthesia using an atomiser with high oxygen flow. Patients were carefully sedated using midazolam and fentanyl. Outcomes included patient tolerance to airway manipulation, haemodynamic parameters, and serial plasma lidocaine concentrations. In all, 27 patients were enrolled in the study (2% cohort n = 14, 4% cohort n = 13). Patient characteristics and time for topicalisation and airway management were similar. Haemodynamic parameters did not change significantly. Tolerance to insertion of the Ovassapian airway, bronchoscopy, and tracheal tube positioning was excellent (12 vs 12 patients, 12 vs 12 patients, and 8 vs 12 patients had no response, respectively, 2% vs 4%). Differences did not reach statistical significance. Peak plasma lidocaine concentration was significantly lower in the 2% group (2.8 (0.8) lg.ml )1 compared with 6.5 (1.0) lg.ml

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Section: Discussionmentioning

confidence: 99%

Airway topicalisation in morbidly obese patients using atomised lidocaine: 2% compared with 4%*

Wieczorek¹,

Schricker²,

Vinet

et al. 2007

Anaesthesia

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“…At induction of anaesthesia, these patients can experience rapid arterial oxygen desaturation [1] and aspiration [2], and difficulties may be encountered at all levels of airway management including ventilation and intubation [3][4][5][6]. Securing the airway using awake fibreoptic intubation is considered to be a safe strategy [7], but this technique requires superior airway anaesthesia if excessive sedation is to be avoided. In the morbidly obese patient, obscured landmarks may limit the usefulness of invasive techniques (such as nerve blocks) to achieve airway anaesthesia [8].…”

mentioning

confidence: 99%

Atomised lidocaine for airway topical anaesthesia in the morbidly obese: 1% compared with 2%*

et al. 2009

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SummaryAirway anaesthesia using atomised lidocaine for awake oral fibreoptic intubation in morbidly obese patients was evaluated using two doses of local anaesthetic. In this randomised, blinded prospective study, 40 ml of atomised 1% (n = 11) or 2% (n = 10) lidocaine was administered with high oxygen flow as carrier. Outcomes included time for intubation, patient tolerance to airway manipulation, haemodynamic parameters, the bronchoscopist's overall satisfaction, and serial serum lidocaine concentrations. Patients receiving lidocaine 1% had a longer mean (SD) time from the start of topicalisation to tracheal tube cuff inflation than those receiving lidocaine 2% (8.6 (0.9) min vs 6.9 (0.5) min, respectively; p < 0.05). Patients in the 1% cohort demonstrated increased responses to airway manipulation (p < 0.0001), reflecting lower bronchoscopist's satisfaction scores (p < 0.03). Haemodynamic responses to topicalisation and airway manipulation were similar in both groups. Peak plasma concentration was lower in the 1% group (mean (SD) 1.4 (0.3) and 3.8 (0.5) lg.ml )1 , respectively; p < 0.001). Airway anaesthesia using atomised lidocaine for awake oral fibreoptic intubation in the morbidly obese is efficacious, rapid and safe. Compared with lidocaine 1%, the 2% dose provides superior intubating conditions. Safe airway management in morbidly obese patients requiring general anaesthesia is of paramount importance and inadequate preparation may have dire consequences. At induction of anaesthesia, these patients can experience rapid arterial oxygen desaturation [1] and aspiration [2], and difficulties may be encountered at all levels of airway management including ventilation and intubation [3][4][5][6]. Securing the airway using awake fibreoptic intubation is considered to be a safe strategy [7], but this technique requires superior airway anaesthesia if excessive sedation is to be avoided. In the morbidly obese patient, obscured landmarks may limit the usefulness of invasive techniques (such as nerve blocks) to achieve airway anaesthesia [8]. Recently, we demonstrated that atomised lidocaine 2% or 4% is an efficacious, rapid and safe method to achieve topical airway anaesthesia in morbidly obese patients. However, the lowest optimum dose was not established [9]. This study was undertaken to compare atomised lidocaine 1% and 2% for airway anaesthesia during awake fibreoptic intubation in morbidly obese patients undergoing bariatric surgery. In a prospective, blinded and randomised investigation, main outcome measures included procedural time, patient tolerance to airway manipulation, haemodynamic parameters and serum lidocaine concentrations. The bronchoscopist's satisfaction level with intubating conditions and patients' tolerance to airway topicalisation were also assessed.

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“…[5] Intravenous (IV) midazolam in a dose of 20 to 40 μg/kg, repeated every 5 min as needed, is used to achieve the desired level of sedation (maximum dose of 100 to 200 μg/kg). Midazolam provides excellent anxiolysis and anterograde amnesia.…”

Section: Introductionmentioning

confidence: 99%

Preparation of the patient and the airway for awake intubation

Ramesh

2011

Indian J Anaesth

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Awake intubation is usually performed electively in the presence of a difficult airway. A detailed airway examination is time-consuming and often not feasible in an emergency. A simple 1-2-3 rule for airway examination allows one to identify potential airway difficulty within a minute. A more detailed airway examination can give a better idea about the exact nature of difficulty and the course of action to be taken to overcome it. When faced with an anticipated difficult airway, the anaesthesiologist needs to consider securing the airway in an awake state without the use of anaesthetic agents or muscle relaxants. As this can be highly discomforting to the patient, time and effort must be spent to prepare such patients both psychologically and pharmacologically for awake intubation. Psychological preparation is best initiated by an anaesthesiologist who explains the procedure in simple language. Sedative medications can be titrated to achieve patient comfort without compromising airway patency. Additional pharmacological preparation includes anaesthetising the airway through topical application of local anaesthetics and appropriate nerve blocks. When faced with a difficult airway, one should call for the difficult airway cart as well as for help from colleagues who have interest and expertise in airway management. Preoxygenation and monitoring during awake intubation is important. Anxious patients with a difficult airway may need to be intubated under general anaesthesia without muscle relaxants. Proper psychological and pharmacological preparation of the patient by an empathetic anaesthesiologist can go a long way in making awake intubation acceptable for all concerned.

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Preparation of the Patient for Awake Intubation

Cited by 13 publications

References 85 publications

Airway topicalisation in morbidly obese patients using atomised lidocaine: 2% compared with 4%*

Airway topicalisation in morbidly obese patients using atomised lidocaine: 2% compared with 4%*

Atomised lidocaine for airway topical anaesthesia in the morbidly obese: 1% compared with 2%*

Preparation of the patient and the airway for awake intubation

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