Fibreoptic/Endoscopic Airway Training Course



Awake Fibreoptic Intubation Course

Date: Wednesday

Time: 08.30 – 14.00

Meet in Anaesthetic Trainees Coffee Room

– 3rd Floor Maples Link Corridor

By Theatres

Venue: 3rd Floor Podium

UCH

Course Organisers

Dr Irene Bouras Consultant Anaesthetist UCH

Dr Simon Clarke Consultant Anaesthetist UCH

Dr Kirstie McPherson Consultant Anaesthetist UCH

Kindly supported by Ambu

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We advise that you must not be on call the night following the course

Programme

Please remain NBM (solids) from 6.00 a.m. – (water up until 08.00 a.m.)--and bring this booklet and signed consent form with you to the course.

08.30 – 09.00 Introduction

Dr Ian Calder’s Video

UCH AFOI DVD

09.00 – 11.00 Mannequin Practice

Handling the scope

Topical Anaesthesia Method

11.00 – 12.00 Practice candidate no.1

12.00 – 13.00 Practice candidate no.2

13.00 – 14.00 Practice candidate no.3

14.00 – 14.30 Q & A, Closure

Airway Endoscopy Under Local Anaesthetic

Before volunteering for an awake fibreoptic endoscopy you will need to understand what is involved, the risks of the procedure and exactly how you can expect to feel during and 8afterwards.

Method

The procedure takes place in an operating theatre with full resuscitation facilities available.

Each delegate will have fasted for at least four hours prior to being endoscoped. To this end, please ensure that you have had a light breakfast (and/or are well hydrated) prior to 6.00 a.m. on the morning of the course (not necessarily starved from midnight the previous night).

Drugs to be drawn up by each candidate as per their own body weight. A 20/22g cannula is inserted into the dorsum of the hand or the antecubital fossa and glycopyrollate 4 – 8 mcg/kg given intravenously. Routine monitoring is established (ECG, NIBP, and pulse oximetry). Topical co-phenylcaine spray is applied to both nostrils.. Oxygen will be administered, followed by the topical application of lidocaine (fine spray throughout the airway via atomiser ). When satisfactory anaesthesia has been achieved, course members will perform airway endoscopy under direct supervision with further application of lignocaine via the fibreoptic scope. Each delegate will perform airway anaesthesia and the endoscopy procedure on the other 2 delegates in turn. Pulse, BP and Sa02 will be monitored at frequent intervals during the procedure. Local anaesthetic injections, cocaine or sedation will NOT be used.

Risks

Trauma to the airway including bleeding or perforation and abscess formation

Allergic reactions to lidocaine, glycopyrrolate, co-phenylcaine, preservatives in local anaesthetic solution, latex etc.

Hypertensive response with co-phenylcaine

Drug toxicity due to lidocaine

Aspiration of gastric contents

Infection: localised or systemic

With the exception of minor nasopharyngeal trauma, none of these complications are seen commonly. Doses of lidocaine applied to the airway are large (up to 9mg/Kg). These have been found to be acceptable in-patients undergoing bronchoscopy (Efthimiou J, Higenbottam T, Holt D, Cochrane GM. Plasma concentrations of lidocaine during fibreoptic bronchoscopy. Thorax 1982; 37: 68-71). Awake fibreoptic intubation has been reported to be safe in patients at high risk of aspiration (Ovassapian A, Krejcie TC, Yelich SJ, Dykes MHM. Awake fibreoptic intubation in patients at high risk of aspiration. Br J Anaesth 1989; 62: 13-16).

How Does it Feel?

There is obviously a degree of apprehension associated with anticipation of an awake intubation. It is advisable to ensure an empty bladder as the whole procedure may take up to an hour.

You will be settled in the supine position with head elevated on an operating table and monitoring will be applied - NIBP, ECG and pulse oximetry. A small cannula will be inserted into the back of your hand or the antecubital fossa. Early preparation includes the application of a vasoconstrictor to the nose; this is a little uncomfortable and sometimes makes the eyes water.

This is followed by the IV administration of Glycopyrrolate 4mcg/kg. Over the following ten minutes the glycopyrrolate will produce a dry mouth. Topical application of local anaesthetic spray to the airway tastes unpleasant. Lidocaine has a bitter taste and may produce coughing or gagging. Too early advancement of the scope, before adequate anaesthesia, may also cause coughing etc.

When the larynx ceases to react to further increments of local anaesthetic the fibreoptic scope will be passed through the cords. In general the procedure is well tolerated. The position of the scope is confirmed & then removed.

You may feel a certain degree of elation when the procedure is over. This sensation is enhanced by the effects of lidocaine which produces some dysphoria. Following the procedure the subject will be aware of a dry mouth and of nasal stuffiness. When oro-pharyngeal sensation returns to normal we recommend a warm cold-cure drink containing paracetamol to deal with the nasal and throat discomfort. Both usually settle after 12 to 14 hours. Other useful things to have available are a Lipsyl stick for the dry mouth and some Vicks vaporub, which eases nasal stuffiness overnight.

Clearly in a course of this kind, it is essential that we exercise the utmost caution. For this reason we are explicit about the risks and some candidates may be refused entry as participants.

Participating candidates must not drive for 4 hours after endoscopy. We also advise that you must not be on call immediately following the course.

We would be grateful if you could fill out the feedback form (at the end of the booklet) after the course and telephone or email us the following day to let us know how you are feeling and if you had any problems overnight.

Equipment

Fully operational scope/ TV monitor- set up & checked

Monitoring equipment / Resuscitation facilities, Assistant.

Suction apparatus

Oxygen supply; Face mask/ nasal sponge, green tubing

Different type/size ETT’s (6.0, 6.5 flexible reinforced ETT’s)

Split oral airway (Berman)

IV cannula, Glycopyrrolate 4 – 8 mcg/kg, Co-phenylcaine 2.5mls

Green Oxygen tubing attached to a 3 way tap and 20G Canulla with Oxygen/Air at 10 -15L/min

Epidural Catheter 16 G (with tip cut off)

2% lidocaine gel (“Instillagel”) -2ml to nostril and 5ml to mouth to gargle

1% lidocaine 10ml via High Flow Oxygen/Air attached to 20G Cannula over back of tongue directed to larynx

4% lidocaine 2ml x 3 (in 5ml syringe with 2ml air)

Warm sterile saline (to soften tube), KY Jelly (nose)

Saline (lubrication for railroading tube over scope – not performed on course!)

Additional Equipment etc: -

Oral airway devices, Berman oral airway size 8 & 9, bite blocks, laryngoscopes, LMA’s, naso-pharyngeal airways

Sedation/analgesia- midazolam 1mg/ml, fentanyl 10ucg/ml, propofol 10ml/hr (not performed on course)

Gloves, Tissues

Platform to stand on!

Local anaesthesia for awake fibreoptic intubation

Maximum Dose of Lidocaine (9mg/kg)

Calculate personal dose according to weight

Average 60kg woman = 540mg

Average 70kg man = 630mg

2.5ml syringe – 2-2.5ml co-phenylcaine (50mg/ml lidocaine, 5mg/ml phenyephrine) 120mg 120mg

2ml syringe – 1-2ml glycopyrolate (4- 8mcg/kg)

10ml Instillagel syringe – 6ml 2% lidocaine / 8ml 2% 120mg / 160mg

10ml syringe – 10 mls 1% lidocaine 100mg 100mg

5ml syringe x 3 – 1.5ml 4% lidocaine and 2ml air 180mg 180mg

Total lidocaine dose 520mg 560mg

Airway anaesthesia

3 Targets 3 Nerves

1. Nose and anterior tongue Trigeminal

2. Oropharynx, posterior tongue and gag Glossopharyngeal

3. Larynx. Vagus

(Supraglottic - Superior laryngeal nerve)

(Infraglottic - Recurrent laryngeal nerve)

Ten Step Technique

1. Calculate the toxic LA dose

2. Standard monitoring and intravenous access

3. Intravenous glycopyrolate according to weight(4 – 8 mcg/kg)

4. Intranasal co-phenylcaine 1 - 1.5mls to best nostril .Remaining solution to the other nostril because of dual innervation .

5. Intranasal instillagel 2 - 3 ml to sniff

6. Intraoral instillagel 4ml to gargle for 1 minute then suction and test gag

7. Intraoral 1% lidocaine. 10 ml sprayed toward larynx with 20G cannula connected to high flow Oxygen with tongue extruded and patient mouth breathing and ‘panting’

8. Spray as you go via epidural catheter with 1.5ml increments of 4%

lidocaine directly onto cords under direct vision with the scope

9. Spray as you go via epidural catheter with 1.5ml of 4% lidocaine

through cords onto tracheal mucosa under direct vision with scope if

planning to railroad endotracheal tube

10. If attempting awake oral and gag a problem despite above measures

then optional extra intraoral 10% lidocaine spray to each side of

oropharynx.

Consent to Endoscopy +/- Intubation under Local Anaesthesia

As a voluntary participant on this course, this will involve undergoing fibreoptic nasotracheal & orotracheal endoscopy, and possibly naso/orotracheal intubation under local anaesthetic.

There may be some discomfort, namely nasal & airway irritation during the procedure, which causes coughing, and a dry mouth & nasal stuffiness afterwards, lasting several hours. Candidates will have fasted for at least 4 hours prior to the procedure and are advised to fast for approx. 2 hours post procedure and not to drive for 4 hours afterwards.

Risks to be aware of include: -

Trauma to the airway including bleeding or perforation

Allergic reactions to lidocaine, glycopyrolate, xylometazoline or preservatives in local anaesthetic solutions

Hypertensive response with phenylephrine

Drug toxicity due to lidocaine

Aspiration of gastric contents

Infection; localised or systemic

Consent:

I wish to take part in this endoscopy airway training course. In doing so, I am willing to act as a subject for endoscopy +/- intubation under local anaesthesia. I have fasted as per recommendations. I am also aware of the side effects of the procedure and the possible risks/complications of the procedure listed above.

Name (Print)……………………………………………

Signature ……………………Date …………………

AFOI Feedback Form

1. What was your overall impression of the course? (Circle one)

Very poor / Poor / Fair / Good / Excellent

2. How did you find the experience of endoscopy on yourself? (Circle one)

Very distressing / Distressing / Acceptable / Enjoyable / Very enjoyable

3. What, if any, aspects of the endoscopy did you find unpleasant?

Pain / Anxiety / Coughing & Gagging / Other sensation (please specify)

a. At what stage did they occur?

4. Did you feel that you experienced any of the recognized side-effects of local anaesthetic drugs? Yes / No

a. If Yes, please specify symptoms

b. At what stage did they occur?

c. How were they resolved and was this adequate?

5. Do you feel you have achieved the aims set out at the beginning of the course? Yes / No

6. Would you feel confident about performing an awake fibreoptic intubation on a patient? Yes / No

7. Would you recommend this course to a colleague? Yes / No

a. If yes, why?

b. If no, why not?

8. How do you think the course could be improved?

9. Any other comments?

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