hello everybody I my name is Laura Duggan I'm an associate professor at the University of Ottawa here in Canada in the department of anesthesiology and pain medicine and welcome back so I wanted to take a deeper dive into awake intubation with this talk I mentioned to consider a wake techniques with blunt and penetrating Airway trauma um particularly with blunt trauma in terms of an awake technique by way of a low trach penetrating Airway trauma can be done usually post-induction but there is going to be times where you're going to be worried about that area and want to do it awake so how do you do an awake intubation now you and I are clinicians first and foremost so what we want is a successful awakened Nation almost a hundred percent of the time we want a dense Airway block where we don't want to have to depend on sedation to try and make that patient more compliant because they're gagging and coughing and being very uncomfortable so I'm going to go through with you what I use for my awakened patients again a lot of this will be distilled down from facts and from about 20 years experience now with anesthesia as well as a few years experience in emergency medicine prior to that and I've mentioned this in my previous talk but how do you maintain your wake intubation skills and so that's going to be very important to do and it is difficult to do because we only do them about even one percent of the time at maximum in the operating room maybe two percent in our ENT room where we do repeated Airway operations we need to actually practice evidence-based decision making and procedural skills I.E the cry Q learned from 10 years ago may not be the best evidence now and we need to avoid siloing and soloing in terms of our Airway management there is nothing to be ashamed of if you don't know how to do a particular skill and other people need to be there for for you together to decide what to do best and that also includes sometimes having other Specialties involved in fact I love having an ENT surgeon in the room when I'm doing the complex Airway so here's the first question why bother with awakened debation when I have a VL now that video laryngoscopy is becoming standard of care uh not Direct laryngoscopy in my humble opinion most Airway management should be done as first pass success in with video laryngoscopy as opposed to direct laryngoscopy and I now see VL as standard of care and DL as an advanced technique for certain particular Airways why bother when BL is available and the answer is and this is only one of many studies that have now come forward but this is out of Halifax showing that even in the best of hands in the airway room in the thoracic room for anesthesia awake intubation continues to occur approximately one percent of the time in that black Arrow or sorry black line down at the bottom of the screen despite having video laryngoscopy or approximately a decade so there will always be patients that need awakened debations and why is that there's two different reasons for that to be which is the anatomically difficult Airway the patient at the top of your screen is long-term burn patient who is presented with a suicide attempt and has polypharmacy not really sure what clearly a very anatomically difficult Airway in all spheres through that intubation supraglottic device insertion for rescue oxygenation the ability to be VM this patient or even to do a crime the patient that you see next down at the four o'clock position where it's always a bad sign if there's a respiratory therapist pacing that and forth with that patient he presented with a post-anterior cervical spine fusion bleed and a deviated trachea very small environmental distance and you can tell he's going to be tough for all those spheres again and then finally you see in the approximate eight o'clock position a woman with Ludwig's angina and in my opinion Ludwig's angina is the thing that makes me most concerned in terms of head and neck infection Ludwig's angina takes up the space that I want to put a tongue into that space at the bottom of the jaw the submental space takes it up with infection pushes the epiglottis back and everything all tissues become very edematous and difficult to manipulate this is a very difficult Airway all of these patients are sitting up because they cannot lie down and be comfortable and then finally and shout out to Jared Moser in at the University of Arizona for recognizing and articulating so well with data and evidence that we need to start paying more attention to the physiologically difficult Airway and by that uh right-sided failure that you can see this patient at the two o'clock position is he's got lower pneumonia and he's failing and there's a lot of reasons why he will not be pre-oxidated no matter what you do is physiology as well as his Anatomy quite difficult in the four o'clock pulmonary embolus waiting to be born from a DVT and right-sided failure just waiting to happen so as soon as you start positive pressure ventilation on this patient this is a mid esophageal four chamber view on trans-esophageal Echo in the left side of your screen is actually the right side of the heart and then at the eight o'clock position you see a woman who is actually having fatal distress who has all the physiologic changes of of being pregnant as well as class 3 obesity as well as a very small environmental distance and an overbite so again physiology and Anatomy can come together and then of course physiology and Anatomy that we see sometimes in the post cardiac surgery patient but also knife ones to the chest etc etc so all of these very physiologically difficult so this is where I don't want to induce positive pressure ventilation I want to maintain the patient's own spontaneous or negative pressure ventilation so an awake intubation you just manage getting that tube in that's all you manage and the patient manages their Airway protection and gas exchange but if you'd elect because you're somewhat avoidant of Awakened debation because you're not comfortable with it you haven't really done it before or you don't want to have the same experience you had last time with the patient crying and bucking and slapping their arms and you elect to do a patient like this post-induction you need to manage their gas exchange they will decide immediately their Airway patency and protection they will completely collapse their Airway particularly in the setting of Ludwig's angina or post-surgical bleed of the neck and getting the tube in at the same time and the patient doesn't manage a damn thing so if you want to get a team approach to a very difficult physiologic and anatomic Airway make the patient part of that team make them do some of the jobs while you're getting that too then so awake intubation Made Simple so this is my Approach lycopyrolate is great in that it dries up secretions but it also maintains a heart rate when somebody's getting severely hypoxic at least they're not getting severely myocardic at the same time but you're gonna need five to twenty minutes depending on how you give glycopyrrolate so consider it early if you get called just just get it in and if you don't you don't remember it it's not the end of the world the sedation we're going to call it we're going to talk about uh briefly equipment and topicalization I'm gonna I'm gonna really hone in on that moving forward sedation none just see what I did there um so don't use sedation for awakened patient don't set up some fancy schmancy Remy or Dex medical infusion don't use sedation as a crutch to poor topicalization and disclosure on one of the in Canada I'm one of the Royal College examiners for anesthesiology for getting your certification in anesthesiology for for our country and I hear candidates coming for their exam talk a lot about judicious sedation and my response is judicious sedation is a descriptor only made in retrospect I have seen patients completely conk out with half a milligram in the midazolam particularly if they are physiologically stressed and anatomically stressed do not sedate these patients rely on your topicalization Technique equipment should be maintained and not look like this this was uh this was the drawer that I opened when that patient that I just showed you came in with Ludwig's angina it's a dog's breakfast and that's completely unacceptable so even if you don't use it very often they make sure that it looks like an Ikea showroom of everything that you need very easily laid out and I have no idea why we have so much lubricating jelly for an airway so topicalization most of the time when you pick up lidocaine it says two percent lidocaine make sure you get four percent lidocaine for topicalization and topicalization you know think about nebulization versus atomization and I don't mean to go down a rabbit hole of ridiculousness but this actually matters to really think about this you want to actually topicalize three different nerves you don't need the first two thirds of the tongue you need the posterior one third of the tongue so you don't have to spread a lot of stuff in the anterior tongue just the back where the trigeminal nerve is you then want to topicalize above the glottis above the entry point where the vocal cords are and the false vocal cords and the arachnoids are and that's glossopharyngeal and then you want to topicalize the internal branch of the superior laryngeal and the recurrent branch of the vagus nerve I always get that mixed up but anyway that could come up on a question just saying so atomizers produce very large particulates 50 microns nebulizers is what we use in asthma and other things to get it down to the terminal molecules so if you want to topicalize up here you need big fat droplets to rain down on the airway as opposed to getting it more systemically in the lower airway through smaller droplets above five microns so this is actually a study very nice in the American Journal of emergency medicine that came out in 2014 looking at Micron size and I always thought that I was a bit of a geek when I did some aerosol research in the early 2000s but now I'm realizing like we all are kind of interested in aerosol since covet happened so this is what we're talking about in terms of aerosolization the the 10 to 50 microns and if you're a visual learner this is what it looks like so the nebulizer looks like this it's small particulates and that's what it looks like above the airway and so we've just done a nasopharyngoscopy and a mannequin here and just recorded what what nebulizing looks like in a mannequin atomizing looks like this it is turbocharged local anesthesia it goes where you want it to these atomizers have an articulating end so you can actually rain down atomized local anesthesia right into the glottic opening or that you just ask the patient to stick out their tongue and breathe like this low tidal volumes but a little bit faster than their usual respiratory rate and look at that that is a winter in Vancouver that is just rains down and if you try this yourself with four percent lidocaine you will find approximately three sprays in about two minutes you'll be able to put in your own oral Airway and I'm not kidding you can consider doing it just to have that sense of onset of action so in terms of how to get glossopharyngeal so the atomization will get you the internal branch of the recurrent laryngeal and the recurrent laryngeal of the or sorry the internal branch of the superior laryngeal which is part of the vagus nerve and then it will also get you below the glottis as the patient breathes it in and so that is the recurrent branch of the radius nerve to get glossopharyngeal are the back of the tongue and lower down into the molecular you really want five percent haste so not gel has a high water content taste is goes where you put it and you don't need a lot of this but order it from Pharmacy five percent lidocaine and again try it on yourself if you take a tongue depressor and make it about as big as your thumbnail and just put it on the back of the patient's tongue ask them to just leave it there tell them it's going to melt down they will eventually cough a little bit and that means that it's melting down into the side walls going down into the piriform fossa and getting bilateral glossopharyngeal nerves so this stuff is Magic it absolutely is magic so don't rely on uh two percent water-based gel it's not going to work I should say it does work only in about 80 percent and you don't want to have that unreliability in the seduction to goes to sedation and this is a resident of mine years ago and done it and he's able to just easily put in his own overlayer way so I don't shove things at patients I get them to put in like I give them a Yonker in their hand while we're doing this and I I keep them sitting up I keep them on nasal oxygen not a huge high flow because it'll it'll uh disperse my local anesthesia maybe about four liters per minute and get them to try with a Yonker if they still have a gag reflex or not so this is actually a really interesting article it's quite current and this was a systematic review a meta-analysis looking at in-awake intubation what is best flexible scope versus video laryngoscopy and what they found was it's the same so what I would suggest to you is if you have VL skills use VL skills for awake intubation you don't have to use flexible skills at all for early intubation and don't use DL it's too much pressure on the tissues and awake patients don't tolerate it feel much less force on the tissues and you still get a really nice first pass success rate and you can see here this is an ICU patient and we're doing VL don't use small screen BL make sure your whole team can see it see what you're doing and be able to help you accordingly and we are not using a combined technique here we're just using a stylated dedicated Glide scope stylet for this intubation and it worked very well for this was again she was an ICU fellow at the time this was her first awake intubation worked really well beware of glottic impersonation and by that I mean if you yard up on somebody's Fairway hard enough the sidewalls of the esophagus can become quite white and get quite pale and if you really want it to be it can look like an airway and so just be very aware trust waveform capnography continuous waveform capnography over your eyes do not trust your eyes even with VL over waveform technography so these are two different references that I would suggest the first one is the difficulty Airway society and their recommendations for awake intubation and so I think that it's very good I disagree with some of the things that they say about sedation when I go to the dentist and I get a root canal they don't sedate me and your patient doesn't have to get sedated awake in division shouldn't be a big deal it should be just what you do and what's part of an airway plan and then finally and this is probably one of the most important Publications right now in 2022 for intubation which is the use and continuous use of waveform capnography and trusting that over anything else including in the in the cardiac arrest patient so skills maintenance as mentioned with trauma skills maintenance is about using nasopharyngoscopy when you absolutely can there's a patient indication for it so I'm not saying go around and do this tip for everybody but if you are curious about the airway and you've done your external exam but you're wondering what's in there go find out what's in there use nasal pharyngoscopy and then get your colleagues to come down and help you do an awake intubation if this is something that you're uncomfortable with in your mind's eye consider whether you're avoiding awakened division because you're uncomfortable with it as opposed to whether the patient may require it and would benefit from it so I would encourage you to call your colleagues in anesthesia and I can tell you this we avoid it too so I have an adage in my practice which is after I'm thinking about using succinylcholine because I don't want it to last for very long because I'm a bit worried about the airway I will do that Airway awake and I would encourage you to actually call and that we'll work together during the week intubation together thanks very much [Music]