A 40 year old man with a history of ankylosing spondylitis and known difficulty with intubation on previous elective surgery is admitted to your ICU for hypoxic respiratory failure. A decision to perform a semi-elective, awake fiberoptic intubation in the ICU has been made.
Describe how you will prepare for this procedure.
Answer and interpretation
Preparation of patient
- Consent/explanation of procedure
- Obtain history of previous airway difficulty, technique used, complications, etc. (from patient, letter from anaesthetist).H/o allergies-esp. to local anaesthetics. Fasting status. Other co-morbidities, eg. coagulopathy.
- Clinical assessment- of airway itself, mouth opening, nasal cavity/septum, range of neck movement, mental status including ability to understand and cooperate with proposed procedure, degree of hypoxia and ability to pre-oxygenate.
Preparation of environment/personnel
- Appropriate lighting with ability to dim.
- Monitoring – ECG, pulse oximetry, arterial line, capnography set up.
- Adequate and working IV access
- Establish comfortable and adequate patient position, pillows, etc.
- Request help and ensure availability as appropriate- eg. Anaesthetist
- Ensure presence of adequate skilled assistants. Inform them in detail of steps of procedure and assign roles, as appropriate.(eg. observation of patient, administration of sedatives, optimisation of patient position, injection of LA, etc) Discuss a plan B, if technique were to fail.
- Keep resuscitation trolley easily available and ensure difficult airway equipment available.
Preparation of equipment
- Check oxygen source and suction
- Check equipment for bronchoscopy- Intubating bronchoscope, light source, lubricant, suction for bronchoscope, (oxygen can be applied alternately through same port using 3-way tap) and injection port for local anaesthetic. Apply defogging solution, if available.
- Airway equipment- range of oral and nasal armoured tubes of appropriate size, oral intubating airways, soft nasopharyngeal airways, appropriate size laryngeal mask airway. Depending on choice of oral or nasal intubation, check, lubricate and load chosen tube onto bronchoscope.
- Equipment required for plan B.
Preparation of drugs
- Antisialagogue – eg. glycopyrrolate
- Consider proton pump inhibitor.
- Midazolam/Fentanyl as appropriate (small doses as patient should be able to cooperate)
Local anaesthetics – Very important in order to achieve success. Ensure not to exceed recommended doses and allow adequate time to act.
- Nasal cavity and nasopharynx- 10% lignocaine spray with phenylephrine spray or cotton tipped pledgets soaked in 4% cocaine or nebuliser filled with 5ml of 4% lignocaine.
- Oral cavity and oropharynx- 10% lignocaine spray or 2% lignocaine viscous gargles.
Extra local anaesthetic may be required to spray during advancement of bronchoscope.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.