Awake Intubation Plan

Overview

• The lecture focuses on achieving complete airway anesthesia for awake intubation in under 5 minutes.
• Emphasis on using nerve blocks for effective anesthesia rather than relying solely on sedation.

Importance of Airway Anesthesia

• Awake intubation can be challenging due to:
  • Rich innervation of the airway.
  • Need to block at least six nerves for effective anesthesia.
  • Local anesthetics often fail if secretions block absorption.

Key Nerves Involved

1. Glossopharyngeal Nerve (GP)

   • Innervates the tongue, pharynx, and part of the epiglottis.
   • Responsible for the gag reflex.
   • Key anatomy includes anterior and posterior tonsillar pillars.

2. Superior Laryngeal Nerve

   • Branch of the vagus nerve.
   • Innervates the inlet to the larynx and parts of the vocal cords.
   • Runs along the thyrohyoid membrane.

3. Recurrent Laryngeal Nerve

   • Another branch of the vagus.
   • Innervates areas below the vocal cords.
   • Key for anesthesia of the cords and trachea.

Suggested Blocks for Anesthesia

General Supplies Needed:

• 22 gauge spinal needle
• 4 x 3mL syringes
• 1 x 10mL syringe
• 25 or 23 gauge needles
• 20mL of 2% Lidocaine
• Tongue depressor
• Skin local anesthetic
• Prep gauze and gloves

1. Glossopharyngeal Nerve Block

• Use 3mL of 2% Lidocaine submucosally.
• Technique:
  • Retract the tongue using a tongue depressor.
  • Target the caudal aspect of the posterior tonsillar pillar.
  • Aspirate and inject 3mL after advancing the needle 1cm.
• Tip: If aspirating blood, redirect the needle more medially.

2. Superior Laryngeal Nerve Block

• Use ultrasound to locate the thyrohyoid membrane.
• Technique:
  • Insert needle out-of-plane to inject Lidocaine deep to the membrane.
  • Use small puffs of saline to confirm needle tip location.
  • Inject 3mL of local anesthetic.
• Safety Note: Avoid the superior thyroid artery.

3. Recurrent Laryngeal Nerve Block

• Access via the cricothyroid membrane.
• Technique:
  • Advance needle through the cricothyroid membrane to inject Lidocaine into the airway.
  • Coughing during injection is normal and helps spread the anesthetic.
  • Can use either a needle with a cannula or directly inject with a needle only.

Ultrasound Guidance Tips

• Use linear ultrasound to visualize the trachea and identify the cricothyroid membrane.
• Position the probe in the sagittal plane to find tracheal rings and the membrane.
• Mark the skin for injection based on ultrasound findings.

Additional Notes

• Consideration for patients with limited mouth opening or infection.
• Avoid topicalization methods in emergency situations due to ineffectiveness and time consumption.
• This technique is quick, well-tolerated, and uses a safe dose of Lidocaine.

Conclusion

• Demonstrated technique allows for effective awake intubation when performed correctly.
• A well-executed airway block can significantly improve the success of awake intubation.