Awake intubation: Difference between revisions
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It is important to maintain spontaneous breathing, provide anxiolysis, ensure adequate comfort, and minimize secretions | It is important to maintain spontaneous breathing, provide anxiolysis, ensure adequate comfort, and minimize secretions | ||
*Antisialagogue | *Antisialagogue | ||
** '''[[Glycopyrrolate]]''' - | ** '''[[Glycopyrrolate]]''' - typically preferred over atropine, provide 0.2 mg IV (onset 1-2 minutes) | ||
* Local anesthetics - though may require time, adequate local anesthesia significantly increases success rate and patient compliance | * Local anesthetics - though may require time, adequate local anesthesia significantly increases success rate and patient compliance | ||
** '''[[Lidocaine]]''' - various formulations, such as topical, atomized, or nebulized to allow for numerous delivery techniques | ** '''[[Lidocaine]]''' - various formulations, such as topical, atomized, or nebulized to allow for numerous delivery techniques | ||
** '''[[Cocaine]]''' - potent topical anesthetic and vasoconstrictor, useful in blind or awake nasal intubations | ** '''[[Cocaine]]''' - potent topical anesthetic and vasoconstrictor, useful in blind or awake nasal intubations | ||
** '''[[Cetacaine]]''' - topical combination anesthetic, useful to provide adjunct anesthesia to the mucosal surfaces of nares or posterior pharynx | ** '''[[Cetacaine]]''' - topical combination anesthetic, useful to provide adjunct anesthesia to the mucosal surfaces of nares or posterior pharynx | ||
* Sedation - must be mild to avoid respiratory depression or apnea. Sedation is frequently required for patient tolerance | * Sedation/anxiolysis - must be mild to avoid respiratory depression or apnea. Sedation is frequently required for patient tolerance | ||
** '''[[Midazolam]]''' - used in small boluses, but has no analgesic properties (may use fentanyl in addition) | ** '''[[Midazolam]]''' - used in small boluses, but has no analgesic properties (may use fentanyl in addition) | ||
** '''[[Propofol]]''' - challenging to balance sedation | ** '''[[Propofol]]''' - challenging to balance sedation | ||
** '''[[Dexmedetomidine]]''' | ** '''[[Dexmedetomidine]]''' | ||
** '''[[Remifentanil]]''' - rapid offset of action | ** '''[[Remifentanil]]''' - rapid offset of action | ||
** '''[[Ketamine]]''' | |||
=Example of Technique= | |||
* Preoxygenate the patient | * Preoxygenate the patient | ||
* Position the patient | * Position the patient | ||
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==References== | ==References== | ||
*Awake Intubation. British Journal of Anaesthesia https://academic.oup.com/bjaed/article/15/2/64/248570 | |||
*Sanchez A, Iyer RR, Morrison DE. Preparation of the patient for awake intubation. In: Hagberg CA, editor. Benumof's Airway Management: Principles and Practice. Philadelphia: Mosby-Elsevier; 2007. pp. 255–80 | |||
<references/> | <references/> | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category:Procedures]] | [[Category:Procedures]] | ||
Revision as of 14:04, 16 March 2018
May use any of the following techniques:
- Fiberoptics (most common)
- Direct Laryngoscopy
- Video Laryngoscopy
- Blind Nasal intubation
- Tracheostomy
Indications
When masked ventilation or intubation is suspected to be difficult, such as those with complicated anatomy or cannot tolerate supine positioning
Contraindications
Patient compliance or refusal
Drugs
It is important to maintain spontaneous breathing, provide anxiolysis, ensure adequate comfort, and minimize secretions
- Antisialagogue
- Glycopyrrolate - typically preferred over atropine, provide 0.2 mg IV (onset 1-2 minutes)
- Local anesthetics - though may require time, adequate local anesthesia significantly increases success rate and patient compliance
- Lidocaine - various formulations, such as topical, atomized, or nebulized to allow for numerous delivery techniques
- Cocaine - potent topical anesthetic and vasoconstrictor, useful in blind or awake nasal intubations
- Cetacaine - topical combination anesthetic, useful to provide adjunct anesthesia to the mucosal surfaces of nares or posterior pharynx
- Sedation/anxiolysis - must be mild to avoid respiratory depression or apnea. Sedation is frequently required for patient tolerance
- Midazolam - used in small boluses, but has no analgesic properties (may use fentanyl in addition)
- Propofol - challenging to balance sedation
- Dexmedetomidine
- Remifentanil - rapid offset of action
- Ketamine
Example of Technique
- Preoxygenate the patient
- Position the patient
- Switch oxygenation from face mask to nasal cannula
- Topical anesthesia
- May be done via transtracheal route, allowing for possible Seldinger cricothyroidotomy, if necessary as a back-up.
- Light Sedation
- Visualization of anatomy
- Intubate
- Confirm Placement
- Secure Endotracheal Tube
- Sedation/analgesia for patient
See Also
References
- Awake Intubation. British Journal of Anaesthesia https://academic.oup.com/bjaed/article/15/2/64/248570
- Sanchez A, Iyer RR, Morrison DE. Preparation of the patient for awake intubation. In: Hagberg CA, editor. Benumof's Airway Management: Principles and Practice. Philadelphia: Mosby-Elsevier; 2007. pp. 255–80