A problem based approach to awake flexible optical intubation€¦ · g. 7. After passing the vocal...
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Transcript of A problem based approach to awake flexible optical intubation€¦ · g. 7. After passing the vocal...
Inhoudsopgave1. Summary2. Introduction3. BasicPrinciples4. ScopeHandling5. Overview6. AProblemswithvisibility
a. 1.Thereiscompletewhite-outofthelensb. 2.Foggingofthelensc. 3.Thereisnovisibilityatalloraredd. 4.Secretionsormucousobscuresvisibilite. 5.Fieldofvisionappearstoosmallf. 6.Imageblurredonmonitorg. 7.Afterpassingthevocalcordswiththe
7. BTechnicalproblemsa. 8.YourDepartmentofAnaesthesiahasfinab. 9.Suctionisnotworkingc. 10.Lossoflightsource
8. CProblemswithadvancementofthetracheaa. 11.Thetrachealtubecannotpassthenoseb. 12.PoorcontroloftheETT,tubekeepsslc. 13.Unabletomanoeuvretheendoscopetowad. 14.Scopestickingtotrachealtubee. 15.Thetubecannotbepassedthroughthef. 16.Tipoftheflexibleopticalscopecanng. 17.Thedistalinsulationrubberprotectio
h. 18.ThenasalRAE™tubeistoolongandthi. 19.Thebronchoscopeisinadvertentlypassj. 20.Aftercorrectintubationofthetrachek. 21.Cannotadvancethetubeduringoralin
9. DProblemswithtopicalisationoftheuppea. 22.Thepatienthasalaryngealspasmafteb. 23.Inadequatetopicalisationc. 24.Theairwayisnotanaesthetizedatalld. 25.Thepatientexperiencesanacuteuppere. 26.“Spray-as–you-go”(SAYGO)techniquenof. 27.Thepatienthasanknownallergytolig. 28.Almosttotalairwayocclusionoccursr
10. EBleedingproblemsa. 29.Themucosaorintraoraltumourstartsb. 30.Epistaxisdirectlyafterintroduction
11. FOxygenationproblemsduringAFOIa. 31.Patientdesaturatesbeforeorshortly
12. GAnatomicalproblemsa. 32.Alargesupraglotticmassortheepiglb. 33.Itisnotpossibletofindandidentifc. 34.Themouthopeningislessthan2.5cend. 35.Thelarynxisdeviatedanteriorly,whie. 36.Itisnotpossibleorcontra-indicatedf. 37.Cannotgetintravenousaccess,buthavg. 38.Theairwaydiameterappearstobetooh. 39.Itisimpossibletopassthebaseoft
13. HProblemswithsedationa. 40.Thepatientisunconscious
b. 41.Thepatientbecomesapnoeicduringthe14. IProblemswithpatientcooperation
a. 42.Thepatientisaggressiveb. 43.ThepatientstartsvomitingduringAFOc. 44.Thepatientissneezingcontinuouslyad. 45.Thepatientbitesontheinsertioncore. 46.Thepatientrefusesanawakeintubatio
15. JProblemswithflexibleopticalscopesina. 47.Itisimpossibletopassthefiberscopb. 48.ItisimpossibletoadvancetheETTthc. 48.ItisimpossibletoadvancetheETTthd. 49.ThetrachealtubecanpasstheLMAbue. 50.Yourplanistoperformanoralflexib
16. KVentilationoroxygenationproblemsaftea. 51.Aftervisualcorrectplacementoftheb. 52.AfterintubationwithanMLTtubeitic. 53.AfterAFOIandtheuseofaRAEnasald. 54.Aftervisualguidedflexibleintubatio
17. LLogisticproblemsa. 55.Icannotstandbehindthepatientbecab. 56.Theheadandnecksurgeonhasnotyetc. 57.DuringtheAFOIyourpresenceisurgend. 58.Therearenotenoughpatientsinmysue. 59.Duringtheadvancementprocedureofth
18. MExtubationproblemsa. 60.TheAFOIwasverydifficultanditis
19. Discussion20. Conclusions
21. References
Aproblembasedapproachtoawakeflexibleopticalintubation“Everythingyoualwayswantedtoknowaboutawakeflexibleopticalintubationbut
wereafraidtoask…”
JohannesMHuitink,MDPhD1,NaveenEipe,MD2,AdrianoCocciante,MD,FANZCA3,RalfKrage,MD,PhD1,RenySegal,MD,FANZCA4
DepartmentofAnaesthesiology,VUUniversityMedicalCenter,Amsterdam,TheNetherlands1
DepartmentofAnaesthesiology,theOttawaHospital,Ottawa,Canada2
DepartmentofAnaesthesia.WesternHealth,Footscray,Melbourne,Victoria,Australia3
DepartmentofAnaesthesiaandPainManagement,RoyalMelbourneHospital,Parkville,Victoria,Australia4
PublicationofthisbookwassupportedbytheMobileAnaesthesiologyServiceHollandFoundation.TheauthorsandtheAirwayManagementAcademy(www.airwaymanagementacademy.com)areresponsibleforthecontent.
Addressforyourcommentsorfeedback:Dr.J.M.HuitinkVUUniversityMedicalCenterDepartmentofAnaesthesiologyPOBox7057
1007MBAmsterdam,theNetherlands
Editing:Dr.J.H.BretschneiderFirstedition,September2013AmsterdamISBN:978-94-6228-248-3
NUR:871
Allrightsreserved.
Thisworkmaynotbetranslatedorcopiedinwholeorinpartwithoutthewrittenpermissionoftheauthors.Whiletheadviceandinformationinthisbookarebelievedtobetrueandaccurateatthedateofgoingtopress,neithertheauthorsnorthesponsorcanacceptanylegalresponsibilityforanyerrorsoromissionsthatmaybemade.Theauthorsmakenowarranty,expressorimplied,withrespecttothematerialcontainedherein.
Summary
Awakeflexibleopticalintubation(AFOI)forairwaymanagementisavaluabletechnique,whichhasundergoneseveraltechnicalimprovementsandadaptationsovertime.Despitethistechniquebeingadvocatedbyanaesthesiaandairwaymanagementexpertgroupsaroundtheworldasagoldstandardformanagementoftheexpecteddifficultairway,manyanaesthesiologistsarenotcomfortableusingthetechnique.Thismaybebecauseofalackofexperience,expertiseorinappropriateequipment.TheremayalsobedeficienciesintrainingandclinicalAFOIpracticeopportunities.
InthisbookadviceandtipswillbegiventoimprovetheintubationsuccessrateandsatisfactionofairwaymanagementwithAFOI.WethinkthatthisbookwillhelpimprovetheAFOIexperienceofboththeclinicianandthepatientandultimatelyleadtoimprovedairwaymanagementusingAFOI.WewillsummarizeboththefrequentandrarecausesforfailureofAFOI.Donotbeafraidtoaskthingsthatyoualwayswantedtoknow.
July2013,
Amsterdam:JohannesHuitinkandRalfKrageOttawa:NaveenEipe,
Melbourne:AdrianoCoccianteandRenySegal
R.KrageandN.Eipe
J.HuitinkenR.Segal
A.Coccicante
Introduction
EnthusiasmamonganaesthetiststoundertakeanAFOIrangesfrom“scaredtodeath”through“reluctant”to“hopeful”,withasmallnumberofcolleaguesinthe“confident”group.Thismaybeduetothelackoftheinitialandintensivetrainingrequiredtoacquirethisskill,lackofskillmaintenanceorpoorequipment.Inappropriatepatientselection,difficultpathology,inadequatepreparationofequipmentorpatient,orfailuretorecognizecontraindicationsandpotentialcomplicationsofAFOIaresomeoftheotherfactorsthatmayleadtofailureoftheAFOItechnique1-3.
ThesedifficultiesarefrequentlyencounteredandarethereasonAFOIstillhasafailurerateof0.5-13%4-7.ItistheopinionoftheauthorsthatallphysicianswhomanagepatientairwaysneedtobegoodatAFOI,becausetheywillsomedayintheircareerencounterapatientthatcannotbesafelyintubatedbyothertechniques.Thisreviewisnotanotherarticlefrom‘airwaymanagementmavericks’for‘airwaymanagementdummies’,butasharingofourexperienceswithAFOI.
WethinkthatmanyproblemsfacedduringAFOIcanbeprevented.Wehaveencounteredmanyoftheseproblemsourselvesduringouranaestheticpractiseatmajorcancercentres,publicandruralhospitalsanduniversitymedicalcentresintheNetherlands,Germany,SouthAfrica,Canada,AustraliaandIndiaandduringnumerousworldwideairwaytrainingsessionswithtraineesandcolleagues.WewillfocusonpotentialproblemsthatcanbeencounteredduringAFOI.Wehavetriedtodocumenttheseproblemsasthoroughlyaspossible,withaliteraturesearchand,whereapplicable,photodocumentation.Wehavealsotriedtogivetipsthatcanbeapplicableinmedicalcentresinanypartoftheworld.Itisourhopethatthesetipsmay
helptheanaestheticcommunitytoembraceanairwaymanagementtechniquethatcanbelifesavingwithconfidence.
WethinkthatthisbookisuniqueastoourknowledgethereisnotasingledocumentavailablethataddressesalltheseproblemsrelatedtoperformingAFOIwhilstatthesametimeofferingpracticalsolutions.
Video1
introductiontoAFOI
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Video2
basictechniques
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BasicPrinciples
Wewillusethetermawakeflexibleopticalintubation(AFOI).AnAFOIcanbeperformedwithaflexiblefibreopticscopeorwithaflexiblevideoscopewitha“chipinthetip”.Newhybridscopetechniquesarealsousedthatcombineflexibleopticalsandvideo.Themostcommonlyusedtermintheliteratureisawakefibreopticintubation.WethinkAFOIismoreappropriatenowadays.ThefollowingbasicprinciplesofAFOIhavebeendevelopedforandareroutinelyusedinourteachingandtrainingprograms8-9.Itcannotbestressedoftenenoughthatthesebasicprinciplesshouldbecarefullyobservedandadheredto.
•Preparethoroughlyanddiscusstheplannedprocedurewiththepatientandotherco-workers.
•Ensurethatthepatientfullyunderstandstheprocedureandisfullycooperative.
•AlwaystrytodoanAFOIprocedurewithtwoexperienceddoctors.
•Makesuretheindicationfortheawakeprocedureissound(Fig.1).
Fig.1
•Shareyourthoughtsofyourplanwithacolleague.
•EnsurethatAFOIisnotcontraindicatedwhilstensuringthatthepatientandpathologyaresuitableforAFOI(Fig2).
Fig.2
•Knowexactlyhowtoassembleyourequipmentandcheckthatitisfunctioning.
•KeeppractisingAFOIforconservationofyourskillsovertime.
•Topicalisetheupperairwayinaneffective,safeandeasyway.
•AFOIshouldneverbeperformedinahurryasthiswillgreatlydecreasethechanceofsuccessfultrachealintubation.
•IfyouarenotveryexperiencedwithAFOIstandbehindthepatient.Doingaprocedurefrombehindthepatientmakestheprocedureeasier.Standingbehindthepatientis:safer(noclosecontactwiththepatientwhowillcoughorspitintoyourfaceifyouareunlucky),andeasier(leftisleft,rightisright)andyoucansimultaneouslywatchthemonitorsandsurroundings.Werecommendstandingbehindthepatient,butalsoteachthe“facetofacetechnique”,becauseinsomesituationsstandingorsittinginfrontofthepatientmaybetheonlywaytoproceed,forexampleinsevererespiratorydistresswhenthepatientcannotliedown.
•Ensurethatyouhaveacontingencyairwaymanagementplan,shouldAFOIfail;haveaplanBandCavailableforemergencyairwaymanagement,andmakesureallteammembersarebriefedbeforeyoustarttheprocedure.
•IfyouthinkAFOI,performAFOI
•DoatimeoutprocedurewithyourteamanddoafinalchecklistbeforeyoustarttheAFOIprocedure(seeFig3).
Fig.3
•MemorizethebasicFFFFIberopticintubationprinciplestoguideyouthroughtheprocedure(seeFig.4).
Fig.4
Photo1
difficultintubationtrolley
Photo2
storageboxclosed
Photo3
storageboxopen
Photo4
sizeoftrachealtubetoobiginrelationtofibrescope
Photo5
flexiblescopetipmovent1
Photo6
flexiblescopetipmovent2
Photo7
flexiblescopetipmovent3
Photo8
flexiblescopetipmovent4
ScopeHandling
Morethan80%ofscopemanipulationcomesfromflexingandextendingthewristandthusrotatingthescopehandle.Thishandlerotationmusttranslatetothetipofthescope.Theremaining20%ofscopemovementisachievedbyflexingorextendingthescopetip(achievedbymovingthethumbleveronthescopehandleupordown)andbyscopeinsertion(insertingthecordofthescope).Thescopecannotberotatedfromthetiporthecord,whichisexposedatthepatient’smouthornose.Thescopemustberotatedfromthehandle.Thetipofthescopeisthepartinthepatient’sairwayandhencethetrue“eye”ofthescope,theimageofwhichisthenprojectedontheeye-pieceorscreenifacameraisused.Forthemovementinthehandletofullytranslatetothetip,thecordmustbestraightatalltimes.Anybendorloopinthecord,whichiseasytodoandoverlookinclinicalendoscopy,willcausealessthanequaltranslationofhandlemovementtotipmovement.Thehandlemovementneedstobecoupledtotipmovementinaonetooneratio,notless.Thiswillfrustratetheendoscopist’sabilitytodriveandaccuratelydirectthescope.Thesecondcrucialtechniqueinscopedrivingis,asalreadydescribedabove,havingthenext“target”(theairspaceonthewaytothelarynx,thelaryngealinlet,thecentreofthetrachea,whicheveristhenexttargetintheendoscopysequenceatthetime)centredintheviewfinderorscreen.Toconstantlykeepthetargetinthecentreoftheviewfindertheendoscopeshouldbedriveninthreedistinctphasesknownas“Stop,Centre,Move”(Fig.5).MethodsusedattheRoyalMelbourneHospital,AustraliaandatVUUniversityMedicalCentre,Amsterdam,TheNetherlands.
VIdeo3
facetofaceintubation
00:00/00:00
Fig.5
Photo9
OlympusTMMAF-scopescreen
Photo10
StorzTMTelepackmonitorscreen
Photo11
mobilelightsource
Overview
Incidentsandproblemsmayoccurindifferentways:themostcommonproblemscanbecategorizedinanyofthefollowingcategories4-7,10,11:
AproblemswithvisibilityBtechnicalproblemsCproblemswithadvancementofthetrachealtubeDinadequateupperairwaytopicalisationEbleedingproblemsFoxygenationproblemsduringAFOIGanatomicalproblemsHproblemswithsedationIpoorpatientcooperationJproblemswithflexibleopticalscopesincombinationwithanotherairwaydeviceKventilationoroxygenationproblemsafterintubationLlogisticproblemsMextubationproblems
AProblemswithvisibility
1.Thereiscompletewhite-outofthelensoronthemonitorscreen
•WhenanAFOisdonewithacameraorvideobronchoscope,awhitebalancemustbeperformedbeforeyoustart.
•Decreasethelightintensitymanuallytopreventlightscatterfromilluminationofsaliva
•Onlyuseclearwatersolublelubricationorsiliconelubricationonthefibre-opticscopemakingsurethatthelenstiphasbeenwipedcleanbeforeproceeding.
2.Foggingofthelens
•Thisiscausedbydifferencesintemperaturebetweenthecoldbronchoscopeandthewarmpatient.Thiscanbepreventedby:•Preheatthescopeinwarm
waterbeforestartingtheprocedure,orhavethescopeonforafewminutesbeforestartingtheprocedure.
•Wait10secondsafterintroducingthescopethroughthenose.
•Trytotouchthebuccalmucosagentlywiththetipofthescopetospeeduptemperatureequilibration.
•Useanti-fogsprayorsoapwatertoclearthelens.
•Neverspraythetipofthebronchoscopeortubewithlubricantspray-spraytheinsertioncordonly.
3.Thereisnovisibilityatalloraredblushonthemonitor
•Removethecamerafromthescope,sometimesthismaybeaproblemrelatedtothecameraandnotthebronchoscopeitself.
•Youmayhavecausedbleedingwiththeinsertioncord.
•Tryanotherbronchoscopeifavailable.
•Usenewbatteriesoranewlightsource.
Photo12
redblushimagecausedbybloodduringAFOI
Video4
useoftheBermanTMairway
4.Secretionsormucousobscuresvisibility
00:00/00:00
•Patientsshouldbegivenananti-sialogoguemedicationatleast15minutespriortoprocedure.Werecommendglycopyrrolate0.2-0.4mgivforadults.
•AttachO2at1-2L/minthroughtheworking/suctionportofscope.Thisworksbetterateliminatingandmobilisingsecretionsfromfieldofviewthansuctioningandhastheaddedbenefitofprovidingsomeoxygentoyourpatientduringtheprocedure.Wehavefoundsuctioningsecretionsinthissituationhighlyunsatisfactory.
•Insteadofrepeatedscopewithdrawal,wesuggestgentlyapproachingandbrushingthetipandthusthelensagainstmucosainthehypo-pharynx.Thiswillrapidlycleartheimage.
Photo13
secretionsandmucousobstructvisibility
5.Fieldofvisionappearstoosmall
•ForAFOI,chooseanadultfibre-opticscopediameterof5.0,5.1or5.2mm.Smallerflexibleopticalscopesareusuallyusedfornasalendoscopy,checkingdoublelumentubesandpaediatricpracticeandwillgiveyoua
reducedfieldofvision,inadequateornosuctionability,reduced•manipulationabilityanddifficultyin“rail-roading”antrachealtube(TT)duringtheprocedure.SmallerscopesarealsomorepronetodamagewhenusedforanAFO.
•Checkifthecameracanbezoomedinorout,thismay
•increasethefieldofvision
6.Imageblurredonmonitor
•Manycamerascanbefocussed:yourcameramaybeoutoffocus!
•Adjustthescopefocusbeforetheprocedurebyholdingthescopetiptwocmawayfromprintonawhitebackgroundwhilelookingintotheeye-pieceoronscreenandrotatingthescopefocusdial.Onceinfocus,theprintbeingviewedshouldbereadable.
7.Afterpassingthevocalcordswiththebronchoscopevisionisacutelylost.
•Thismaybeduetoseveralcauses,e.g.mucous,orpoornavigation.Haveyourunintoatumourblindly?Haveyoujustrunintothetrachealwall,againfailuretonavigate?
•Trytorestorevisibilityforexamplebymovingbackthescopealittle,donot
sedatethepatientatthispoint!
•Removethescopeanddonotadvanceitfurtherifthisistoleratedbythepatientandclinicallyfeasibleandcleanthelens.
•ConnectthecapnogramsamplinglinetotheworkingchannelofthescopebeforeremovingitandseeifyoucandetectCO2repeatedlyifvisibilitydoesnotimprove.
•Trytofeelthatthebronchoscopecannotbeadvancedfurtherorthattrachealringsareencountered.Dothisverygentlytopreventdamage.Thescopemayhaveenteredasmallbronchiallumen.Retractthescopecarefully.
BTechnicalproblems
8.YourDepartmentofAnaesthesiahasfinallyboughtabrandnewvideobronchoscopeandnobodyknowshowtooperateit
•Donotstartbeforeyouknowtheequipment,orsomebodyelseknowsexactlywhattodo.
•Askforanotherflexiblescopethatyouarefamiliarwith.
•Getanin-servicecontract.
9.Suctionisnotworking
•Mostcommon–suctionchannelblockedwithsecretion.Solution:highpressure(i/esmallsyringe)salinewashthrough.
•Thesuctiontubingmaybekinked,disconnectedorisleakingsomewhere.
•Alternatively,giveoxygenthroughtheworkingchannel1-2litres/mintocleartheairwayfrommucousorblood,thisworksmuchbetter.Donotusealargeoxygenflow10.
•Haveasecondseparatesuctionfromthesurgical“southside”andattachaYaunkersuctiontiptoit.
10.Lossoflightsource
•Thismaybeduetopowerfailure,atechnicalproblemoremptybatteries.
•Trytofindanotherbatterydrivenlightsource,suchasthelightsourcefromsurgicalcolleagues(laparoscopyequipment,headlightpowersourceetc).
•Useaflashlightandapplythelightdirectlytotheanteriorneckjustbelowthethyroidcartilage.
•Whenurgentintubationisrequired,insertalaryngoscopeorvideolaryngoscopeandusetheselightsourcestoguidethebronchoscope.
•Ifyouuseavideobronchoscopewithamonitorandmanycableconnections,makesureallthecorrectbuttonsareengagedandcablesattached.
CProblemswithadvancementofthetrachealtube
11.Thetrachealtubecannotpassthenoseaftertheinsertioncordoftheflexiblescopehassuccessfullypassedthevocalcords
•Useanasopharyngealairwaytodilatethenostrilcarefully.Thisreallyshouldideallybedonepriortoinsertingthescope.Trytoavoidthesurpriseof‘oops,nowthetubewon’tgothroughthenose‘11.
•Longitudinallycutanappropriatelysizednasopharyngealairway,lubricateitandinsertitintothenares.Passthescopethroughthesplitnasopharyngealairway(SNPA)andafterenteringthetrachea,pulltheSNPAoutandpeelitoffthescope.Thenthreadthetrachealtubeoffthescope.[photo14,seesplitSNPA]
•Useasecondbronchoscopethroughtheothernostrilifvocalcordsweredifficulttovisualizeandusetheotherflexiblescopeasaguide.
•Useasmallertube,insertthistubethroughthenosefirstandthenthescope,bewarenottocauseepistaxis.
Photo14
nasopharyngealairwayinsertedinleftnostrilandsplitnasopharyngealairway(SNPA)insertedinrightnostrilofmanikinwithinsertioncordofflexibleopticalscopeinsertedthroughSNPA.Techniqueused
atTheOttawaGeneralHospital,Ottawa,Canada
12.PoorcontroloftheETT,tubekeepsslippingdownscope
•Tapethetubeconnectortothebaseoftheflexiblescope[photo15]
Photo15
tubeconnectedtobaseofscope
13.Unabletomanoeuvretheendoscopetowardsthedesiredtarget–“won’tgowhereyouwantittogo”.
•Useaguidewireorhollowintubatingcatheter.12-14
•Useanupperairwayguidingdevice,forexampleaBermanTMoralaryngealmaskairway,asaconduitfortheflexiblescope
14.Scopestickingtotrachealtube
•Lubricatetheinsertioncordofthescopebeforeendoscopywithspray.
•DonotuseKYJellyTM,EMLATMcrèmeorthelike–thisdriestooquicklyandbecomessticky.
•Donotuseapetroleumbasedlubricantwhichmaydamagethescope.
•UseeithereyelubricationsuchasLacri-LubeTMoramedicalgradesiliconelubricantspray.
•Neverpushthescopeagainstresistancewhenit’swithinatube.Althoughitprobablywon’tharmthepatient,itwilldamagethescope.Stop,withdrawandlubricate.
Photo16
differentscopesizes
15.Thetubecannotbepassedthroughtheglottisafterintroductionofthebronchoscopethroughthevocalcords
•Normallythisiscausedbylaryngealimpingementonthearytenoidsortheepiglottis,whichcanbepreventedbyusingatubethatfitssnuglyaroundtheinsertioncordofthescope.
•Whenthetubecannotbeadvanced,turntheblueradioopaqueliningonthebacksideoftheETTfromthe“6-o’clockposition”intothe“1-o’clockposition”(clockwiseorcounterclockwiseisokay).Orrotatethetube360degrees.Inthismannerthebevelofthetubewillturnawayfromthearytenoids.
•Thismayalsobecausedbyimpingementofthebevelofthetubeontheanteriortrachealwall.Turningthebluelineofthetubefromthe6inthe“1o-clockposition”normallysolvesthisproblem.Theresearchhereandour
ownexperienceshowsthatbulletsiliconetiptubes,ortheintubatinglaryngealmaskairwaytubesorthe“birdbeaktubes”(ParkerTM)havesignificantlylesshangupatthelaryngeallevel.
Photo17
exampleofathinfibrescopeandarelativelylargetrachealtubewhichresultsinagapbetweeninsertioncordandtubethatmaycauselaryngealimpingementwhenthetubeisadvancedoverthe
scope
16.Tipoftheflexibleopticalscopecannotbeflexedbackbecauseofabreakinthesteeringcable
•Thisisararetechnicalcomplication.
•Removetubeandbronchoscopeasawholeanduseadifferentscope.
17.Thedistalinsulationrubberprotectionoftheinsertioncordiscurledupandmakesadvancementofthetrachealtubeverydifficult
•MakesurebeforeyoustartthattheETTisinspectedandnotdamaged.
•UsealargerdiameterETT.
•Useadifferentflexibleopticalscope.
•Ifyoucannotmovethescopeforwardorbackward,thescopeandtubeshouldbewithdrawnsimultaneously.
18.ThenasalRAE™tubeistoolongandthetipoftubealreadytouchesthenose,beforethetipoftheinsertioncordhaspassedthevocalcords
•Removetheconnectorofthetube,whichwillenablethetubetobeadvanced1.5cmhigheronbaseofthescope.
•Useasmallersizetube,whichnormallyisshorter.
•Shortenthelengthofthetubeandreinsertthetubeconnector.Onlydothisifnootheroptionisavailable,becauseyoumaybeholdpersonallyliableforinadvertentuseofamedicalproduct.
19.Thebronchoscopeisinadvertentlypassedthrough
theMurphy’seyeofthetube
•Trytoretractthescopeverycarefully;thismaybedifficultbecausethetipofthescopewillprobablybewedgedinbetweentheETTandtrachealwall.Ifthisisnotpossibleremovethescopeandthetubesimultaneously15.
Photo18
tipofflexibleopticalscopeOlympusTMLFTP,passedthroughMurphey’seyeofMallinkrodttube6.0
20.Aftercorrectintubationofthetracheawiththetipofthescope,thetubeinadvertentlypassesintotheoesophagus
•Alwaysadvancetheflexibleopticalscopefarenough,almostasfarasthecarina,topreventthisevent!
•Makesurethespacebetweenthetipoftheinsertioncordofthescopeandthetrachealtubeissmall,souseatightfittingtrachealtubethatfitssnuglyaroundtheinsertioncord.
•UseanAintreeintubatingcatheterTM[Photo19]
•Advancetheinsertioncordalmostasfarasthecarinaintothetrachea,beforerailroadingofthetube.
•Keepwatchingthecarinawhileadvancingthetube.
Photo19
flexibleopticalscopeOlympusTMLFGPinsertedinanAintreeTMAirwayCatheter
Video4
facetofaceAFOIwithtopicalisationusingaDeVilbissTM
00:00/00:00
21.Cannotadvancethetubeduringoralintubation
• UseaBermanTMorWilliamTMairwaytoguideintroductionoftheflexiblescope.Wheninsertedproperlythesedeviceswilllifttheepiglottisandbaseoftongue16.
• MakesureyouusethecorrectsizeBermanasitmaybetobigandguideyourscopedirectlyintotheoesophagus.
DProblemswithtopicalisationoftheupperairway
22.Thepatienthasalaryngealspasmafterintroductionofthescope.
• Thisisapotentiallifethreateningsituation.
• Stoptheprocedure,giveoxygenwithpositivepressureventilationandwaitseveralminutesbeforeyoumakeanotherattempt!
23.Inadequatetopicalisation
• TherearemanywaystotopicalisetheupperairwayofapatientforAFOThemostpopularoftheseare:nebulised(viaanebulisingHudsonTMmask),aerosolised(viaaMucosalAtomisingDevice(MADTM)oraDeVilbissTMtypeatomiser).Nerveblocks(blockingthesuperlaryngealblock)ortranstrachealinjectioncanalsobeused.Mostpatientsdonotappreciatenerveblocks.Thenebulisedandatomisedlidocainemodalitiesareshortacting.ItisimportanttostarttheAFOattheinstanttopicalisationhasfinishedandbythe10minutemarkthepatientshouldbeintubatedandasleep.Thattimeframeimpliesahighdegreeoforganisation(patient,equipment,theatrelogistics,staff,sedationtomentionafew)priortostartingtopicalisation.Ifforlocalanaesthesianasalgauzeswithcocaineortetracaineareused,moretimeisavailabletoperformtheprocedure.
24.Theairwayisnotanaesthetizedatallandistooreactive
• Itisdifficulttotopicalisemucosawhichiscoveredwithsecretions.Ensurethatananti-sialologueisadministeredfirst.
• Toomuchtimehasexpiredbetweenpatientpreparationandintubation.Trytotopicalizetheupperawayagain,orusethe“spray-as-you-go-technique”ortranstrachealinjectionoflidocaine17.Becarefulhere,donotgiveatoxicdoseoflocalanaesthetic18.Areasonabledoseforlidocainefortopicalisationis7-9mg/kg.
25.Thepatientexperiencesanacuteupperairwayobstructionaftertopicallidocainehasbeenapplied19.
• Thisisapotentiallifethreateningsituation,thecauseisnotcompletelyclear;itmaybeacombinationofareactiontothelidocaineandsevereupperairwaynarrowing.
• Intubatethetracheaimmediatelyorstoptheprocedure,removethescopeandgivesupportivetherapy.Ifnecessarydonothesitatetoperformacricothyroidotomy.
• Alwaysanaesthetizetheupperairwayinaroomwithaccesstoairwaymanagementequipmentandcardiovascularemergencymedication
• Ifapatientpresentswithaninspiratorystridor,beverycautiouswithtopicalisation,becausetheupperairwaydiametermaybeseverelynarrowed.
26.“Spray-as–you-go”(SAYGO)techniquenotadequate
• Ifyouusesuctionontheworkingchannel,stopsuctioning,thiswillsuctionthelidocaineintothesuctiontubingaswell.Thisisoftenforgotten.
• Uselidocainewithairinasyringe,notjustlidocaine,youwill“drown”yourpatientwithfluids.Bottomlineisthistotaldoseoftopicalisationneedstobe7-9mg/kg.Nomore!
• UseacommerciallyavailablealternativefortopicalizationduringSAYGOtoimprovethequalityofthelocalanalgesia.
27.Thepatienthasanknownallergytolidocaineyetstillrequirestopicalisationoftheupperairway
• Usealternativelocalanalgesiafortopicalanaesthesiae.g.cocainegauzesforthenoseanduseanintratrachealregionalblockwithmepivacaineorropivacaine2mg/mlifnotallergictothesemedications.
28.Almosttotalairwayocclusionoccursrepeatedlywhentheinsertioncordofthescopeispassedthroughtheglotticopening
• Removethescopeandtrytouse“sprayasyougo”forbetterupperairwayanalgesia.
• Useasmallerscope.
• Makesurethereisnotaverysevereairwaynarrowing,orunnoticedsubglotticobstruction.Ifthereisasubglotticobstruction,reconsideryourairwaymanagementtechnique.
• Youcoulduseavideolaryngoscopeincombinationwiththeflexiblescopeiftoleratedbythepatient:thisiscalledavideolaryngoscopyassistedflexibleopticalintubation(VAFOI)20.Itmaystillbeproblematictopassthevideolaryngoscopewiththeinsertioncord.
Photo20
Lidocainspray10%
Photo21
mucosalatomisationdevice
Photo22
XylometazolineHCLnosedrops
EBleedingproblems
29.Themucosaorintraoraltumourstartsbleedingafterintroductionofthescope
• Trynottotouchoral,nasalorpharyngealtissuewiththescope,alwaystrytopositionthescopeinthecentreoftheupperairway.Don’tinsertand/ormovethescopeforwardblindly.Alwayswatchthemonitorwhilemovingthescope.
• Useasuctionsystemthatisattachedtothescope.
• Alternativelyuseoxygenflowthroughtheworkingchanneltoblowawaythebloodandimproveyourvisualfield.
30.Epistaxisdirectlyafterintroductionoftheflexibleopticalscope
• Removethescopewheneverpossibleandattempttostopthebleedingandusetheothernostril.Preparethenosewithavasoconstrictor,forexampleoxymethazolinewhichisusedasadecongestor.
• Useanadaptednasopharyngealairway(seeSNPAandPhoto14)beforepassingthebronchoscopethroughthenosetopreventdamagetothenasalpassages11.
FOxygenationproblemsduringAFOI
31.PatientdesaturatesbeforeorshortlyafterthestartofAFOI
• GiveoxygenbyoxygenprongsormaskoutsidetheOR,whilepreparingtheequipmentorinterviewingthepatient.
• Give0,5-1liters/minoxygenthroughtheworkingchanneloftheflexiblescopeoruseafullfacemask.
• Stoptheprocedureandpre-oxygenatefor3minutesbymaskwith100%oxygen.
• Adaptimmediatelythesedation;ifonlyopioidsareused(recommended)makesuretocooperatewiththe(still)awakepatientbyaskinghim/hertobreathinandout(“commando-breathing!”)
• Useasmallcannula,f.e.14gaugeoraRavussinneedleTMthroughthecricothyroidmembranetogiveoxygen1-2liters/min,thiswillincreasesaturationtoasaferlevel.
GAnatomicalproblems
32.Alargesupraglotticmassortheepiglottispreventsagoodviewatthelaryngealinlet
•Trytopassaguidewirethroughtheworkingchannelandpassthisthroughthevocalcords.Advancethebronchoscopeovertheguidewirebeforethetubeisrailroaded.
•Trytousealaryngoscopeorvideolaryngoscopesimultaneouslytoenableintubationofthetracheawiththescope.
•Usetheawakefibrecapnicintubationtechnique12,13.
•Changepatientposition:patientheadup!
•Usegentlechinlifttoopenuptheairway,ormanipulatethetongue.
Photo23
anatomicalproblemsforintubation.TransversalCTscanoftheheadandneckofapatientwithalargebaseoftonguetumourwhichcrossesthemidline(betweenwhitearrows)andtrachealnarrowing
(yellowarrow)
33.Itisnotpossibletofindandidentifytheglottisduetoanatomicalabnormalities
•Consideranawakefibrecapnicintubation,ahollowsuctioncatheterisadvanceddeeplyintotheairwaytofindconsecutivecapnogramtracingandthiscathetercanbeusedasaguidewiretorailroadthebronchoscopeintothetrachea.12,13
•Askthepatienttotakeadeepbreath.Oftentimesyouwillnoticeairmovement(bubbles).
•DoaVAFOI:videolaryngoscopicassistedflexibleopticalintubation.Trytovisualizethelarynxwithavideolaryngoscopeandadvancethebronchoscopewithguidanceofthevideoimage20.Anepiglottismaybeseverelydistortedorevenmissingbecauseofpriorradiotherapy.
•Asanalternativeyoucoulddoaretrogradeguidewireflexibleintubation,theguidewireisadvancedretrogradelythroughtheglottisandtheguidewireispassedthroughtheworkingchannelofthebronchoscope21.
•Considertoinsertanintubatinglaryngealmaskairwayintheawakepatientaftertopicalisationandusetheitubatinglaryngealmaskairway(ILMA)asaguideforthebronchoscopetofindtheglottis22.
•AlwaysreconsiderifAFOIisreallythemostappropriatetechniqueforyourpatient.
Photo24
fibreopticscopewithfibrecapniccatheter
Video5
AFOIthroughILMA
00:00/00:00
34.Themouthopeningislessthan2.5centimetresandthenosecannotbeusedtointroducetheflexiblescope.
•Ifitisanticipatedthatmouthopeningwillbegreaterafterinductionofanaesthesia,useathinbronchoscopeandMLTtube,anduseageneralanaesthesiawithspontaneousbreathing.
•Consideranawaketracheotomyunderlocalanaesthesia.
•Considerretrogradebronchoscopyassistedintubation21.
35.Thelarynxisdeviatedanteriorly,whichmakesinsertionoftheflexiblescopepassedthevocalcordsimpossibledespiteagoodandclearview
•Advanceaguidewirethroughtheworkingchannelofthebronchoscopethatisusedtorailroadthescopeintothetrachea12,14.
•ChangetheapproachtoanasotrachealAFOIastheaxisofnasopharynxmayalignbetterwithananteriorlarynx.
36.Itisnotpossibleorcontra-indicatedtointubatethroughthenose
•PerformanoralawakeflexibleopticalintubationasmostoftheAFOIcanbedoneorally;consideranintubationaid,forexampleaBermanTMairway.
•IfanappropriatesizedBermanairwayTMorOvassapianairwayTMisnotavailableinsertanregularGuedeloralairwayasabiteblockandproceedwiththeAFOI,withtheinsertioncordnexttotheGuedel.Alternativelyuseadentalbiteblock.
37.Cannotgetintravenousaccess,buthavetodoanAFOI
•Getanotherpairofhands.
•Putinacentralline,ifneededwithultrasoundguidance,beforestartingtheAFOI.
38.Theairwaydiameterappearstobetoonarrowtoaccommodatetheinsertioncordoftheflexiblescope
•StoptheprocedureandtrytoreviewarecentCT-scanorMRIoftheheadandnecktoseeifthismaybecorrect.Useasupraglotticairwayordoatracheotomy.Sometimessupraglotticjetventilationisanalternativeinthissituation,howevertheriskatbarotraumaishigh.
•Useavideolaryngoscopetoestimateifairwaydiametermayindeedbetoonarrow.Sometimesitisverydifficulttotellifairwaydiametersaretoosmall,becauseoftheaugmentationorzoomofthecamera.
39.Itisimpossibletopassthebaseofthetonguewiththeflexiblescope
•UseagauzeandaMagillforcepstoprotrudethetongue.
•Useamandibularmanoeuvre,suchaschinlift,toliftthejaw.
•Useasuctiontube(YankaurTM)topullthetonguebyapplyingittothetipofthetongue;becarefulnottocausebleeding.
•Movethepatienttoanalmostsittingposition,gravitywillworktoyouradvantage.
HProblemswithsedation
40.Thepatientisunconscious
• Stoptheprocedureandallsedation.
• Givereversalmedication.
• Useonlyshortactingmedication,notmorethantwodifferentclassessimultaneously.Agoodcombinationinexperiencedhandsisremifentanilforanalgesiaandpropofolforsedationandamnesia,howeverthereisarelativelyhighincidenceofapnoeawhenusedincombination.Remifentanilaloneiswellpublishedandwellsupportedbuthasthedisadvantagethatisdoesnotcauseamnesia.IfyoustartpractisingAFOIitisprobablywisetostartsedationwithshortactingopioidsonlytopreventcomplicationswithsedation.
41.Thepatientbecomesapnoeicduringtheprocedure
• Askthepatienttotakeadeepbreathandinstructacolleagueoranaestheticnursetomonitorthepatient,usereversalmedicationorwaitandseeifthisispossibleandgivesupportivetherapy.Considerstoppingallsedativemedication.
IProblemswithpatientcooperation
42.Thepatientisaggressive
• Thisisacontra-indicationforanawakeprocedure.
• Trytounderstandtheproblem,reconsidertheneedforawakeintubation.
• Trymoresedationorsedatewithanotherclassofmedicationandaskforhelp.
• Consideramaskinductionusingvolatileanaesthetic.
43.ThepatientstartsvomitingduringAFOI
• Aspirationisnormallynotabigworry,becausethepatientstillhasmostorpartoftheirprotectivereflexes,however,visibilitywillprobablybepoor:stoptheprocedureandconsiderinsertingagastricdrainifatallpossibleorstartsanti-emetics.
• ConsideranAFOI“facetofacetechnique”withthepatientlyingontheside.
44.Thepatientissneezingcontinuouslyafterthenosehasbeenanaesthetizedwithlidocaine
• Stoptheprocedure,wait5minutesordoanoralfiberopticintubation.Wehaveseenthisphenomenonoccasionally.
45.ThepatientbitesontheinsertioncordduringoralAFOI
• UseaBermanTMintubatingairwayorabiteblocktopreventthisfromhappening.
46.Thepatientrefusesanawakeintubation
• ThisisacontraindicationforAFOI.PatientconsentisneededbeforeAFOIisperformed!
• Ifalreadystartedstoptheprocedureanddoanalternativetechnique.
• HaspropersedationbeentriedafterthepatientconsentstoAFOI?
JProblemswithflexibleopticalscopesincombinationwithanotherairwaydevice
47.Itisimpossibletopassthefiberscopethroughtheintubatinglaryngealmaskairway(FasttrachTM)
•Thisisprobablycausedbytheepiglottisliftingbar;ifpossibleinserttheILMAaneworusetheETTtoliftthebarandthenpassthescopebeyond.Thiswillprotectthescope.
•Trytomanoeuvrewiththetipofthebronchoscopeunderneaththeepiglottisliftingbar.
•Performthe“Chandymanoeuvre”,thiswillprobablyalignthedevicewiththeglotticopeningtoenablepassageoftheflexiblescope.Foradescriptionofthismanoeuvrewerefertotheoriginalarticle23.
48.ItisimpossibletoadvancetheETTthroughalaryngealmaskairway
•Makesurethetubefitsthroughthelaryngealmaskfirstduringpreparation.
•RemovethebarswithapairofscissorspriortoinsertionoftheLMA,oruseasupraglotticdevicewithoutbars.Makesuretherearenosharpedgesthatcandamagetheupperairway.
•Thismaybeproblematicinsomepediatriccasesorinsmallpeople.AlwaystrybeforestartingtoensurethattheETTandlaryngealmaskarecompatible.
Photo25
laryngealmaskairway3.0,paediatrictube4.5,OlympusTMDPfibrescopepreparedforpaediatricintubation
Photo26
thyroidtumorwithmassiveneckenlargement
Photo27
swellingfloorofthemouthbecauseofallergicreaction
Photo28
glotticandsupraglotticneoplasmleftvocalcordpretreatment
Photo29
glotticandsupraglotticneoplasmleftvocalcordpostlasertreatment
Photo30
intubationthroughILMA
48.ItisimpossibletoadvancetheETTthroughalaryngealmaskairway
•Makesurethetubefitsthroughthelaryngealmaskfirstduringpreparation.
•RemovethebarswithapairofscissorspriortoinsertionoftheLMA,oruseasupraglotticdevicewithoutbars.Makesuretherearenosharpedgesthatcandamagetheupperairway.
•Thismaybeproblematicinsomepediatriccasesorinsmallpeople.AlwaystrybeforestartingtoensurethattheETTandlaryngealmaskarecompatible.
Video5
AFOI throughLMA
00:00/00:00
Video6
AFOIthroughIgel
49.ThetrachealtubecanpasstheLMAbutisnotlongenoughtobeabletowithdrawtheLMAsafely
•PutinanAintreeTMcatheterfirst,removetheLMAandthenadvancethetrachealtubeovertheAintreeTMairwaycatheterTM
50.Yourplanistoperformanoralflexibleintubationbutoralairwayisnotavailableinthecorrectsize
00:00/00:00
•Useabiteblockornormaloropharyngealairwaynexttotheinsertioncordinsteadofthemoreoptimaldevices.
•Usegentlechin-lift,jaw-thrustmanoeuvreswithanoralbiteblockornormaloropharyngealairwayinsitutopreventthepatientfromdamagingthescopewiththeteeth.
KVentilationoroxygenationproblemsaftertrachealintubation
51.Aftervisualcorrectplacementofthetubeitisnotpossibletoventilatethepatient
• Doacarefulinspectionofthetrachea.ArethereanyobstructionsbelowthelevelofthetipoftheETT?Lookfortrachealstenosis,orairwaytumours.
• Alsoconsideraseverebronchspasm!
• Isthetubereallystillinthetrachea?Ifitisnotpossibletodisplayconsecutivecapnogramsitishighlylikelythatthetubeisnotinthetrachea.
52.AfterintubationwithanMLTtubeitisnotpossibletoreconnecttheconnectoradapter
• UseaMagillforcepstopushbackthetubeandholditinplaceduringwhichtheconnectorisreconnected.
• DonotdisconnecttheadapterbeforeyoudoanAFOI.Thisisnotnecessarywhenapropersizeflexibleopticalscopeisused.Sometimesitisnecessarywhenavideoscopeisusedbecausethecomputerchipispositionedinthetip,whichincreasesthediameteroftheinsertioncord.
53.AfterAFOIandtheuseofaRAEnasaltube,thetubeiskinkedduringventilation
• WhenusingaRAEnasaltubearoundabronchoscope,thesitewherethetubeisbent,tostraightenthetubewhenitisattachedtotheflexiblescopebecomesaweakspot.TrytostabilizethissitewithtapeorbetteruseaMLTtubeifthesurgeonsconcur.
54.Aftervisualguidedflexibleintubationofthetracheaitisnotpossibletodisplayacapnogramonthemonitor
• Firstensureyouareabletoventilatethepatient.Ifunable,your“can’tventilatesequenceorroutine”shouldbeenactedimmediately.
• Clearthecapnographtubingfromfluidsormucous.
• Insufflatemoreairinthepilotballoonofthetubecuff.
• ThetubemayhavebecomeblockedwithmucousormatterafterretractionofthebronchoscopeandadvancementoftheTT.Introducethebronchoscopeagainandcheckforanyobstruction.Tubeobstructionbyintranasalpolypsorpiecesofnasalconchaeafterintubationhavebeendescribed.
• Thecuffofthetubemayhavebeendamagedafterpassagethroughthenose.Arethereanysignsofcuffrupture(forexampleairleakage)?ExchangethetubeoveranTTexchangecatheter.
• Itispossiblethatthetubehascausedafalse-routeorruptureofthetracheal
wallorandhasendedupintheoesophagusormediastinum.Performacarefulinspectionwiththebronchoscope.
LLogisticproblems
55.IcannotstandbehindthepatientbecauseIamtooshort
• Useabenchtostandhigher,lowertheoperatingtable.Trytoprepareyourprocedureascomfortableaspossible.
• Doa“face-to-facetechnique”,eitherinthesittingpositionorwiththepatientlyingontheirside.Rememberthatthiswillaffecttheorientationoftheimagesthataredisplayed.Thesearenotdisplayedinthewayyouareusedto.Youwillfindtheepiglottisinthelowerfieldofview.
56.Theheadandnecksurgeonhasnotyetarrivedatthehospitalandthepatientwithananticipateddifficultairwayneedstobeintubatedurgently
• PrepareforanemergencycricothyroidotomyasaplanBorCandstarttheawakeintubationprocedure.Notonlypalpatebutalsomarkthecricothyreoidmembraneontheskinofthepatientwithamarker,soyouknowwheretogoinanemergency.Rememberproperpositioningofthepatientforthisprocedure.
• Consideratrans-cricoidcannulasecuredinplacebeforeyoustarttheAFOI(withanoxygenflownogreaterthan1-2l/min).Thiswilloxygenatethe
patientandyoucouldusethiscatheterasalandmarktoidentifythetracheaunderlowvisibilityconditions.
57.DuringtheAFOIyourpresenceisurgentlyrequiredatanothersideofthehospital
• Ifpossibleaborttheprocedure.Ifinarush,chancesoffailureincreasedramatically.
• Onepatientatatimeandyourresponsibilityiswiththecurrentpatient.However,anAFOIcanbedonewithin30seconds,soifyouareexperiencedjustfinishtheprocedure.
58.TherearenotenoughpatientsinmysurgicalpopulationtopracticeAFOIroutinely
• Tryvirtualflexibleopticalteachingtasktrainers.
• ConsidertrainingonDexterTM(ReplicantMedicalSimulators,NewZealand)fordexterity.Ithasscientificallybeenproventhatflexibleopticalscopehandlingisgreatlyimprovedbytrainingacoupleofhoursonthisnonanatomicaldevice8
• Doasmanyflexibleintubationsinpatientsundergeneralanaesthesiaviatheoralroute.
59.DuringtheadvancementprocedureofthetubethroughtheglottisduringAFOIitisnotedthatsomebodyhasforgottentoputanETTaroundtheflexibleopticalscope
• Startagain.Neverstartwithoutcheckingalltheequipment.Neverinducegeneralanaesthesiabeforecorrecttrachealtubeplacementhasbeenconfirmed.Remember:thisprocedureiscalledAFOI(intubation)andnotjustbronchoscopy.
• DoachecklistbeforethestartoftheAFOI.(Seefig.3).
MExtubationproblems
60.TheAFOIwasverydifficultanditisnotclearifextubationissafe
Therearegenerallythreesafeoptions:
• Useanairwayexchangecatheter(f.e.CookairwayexchangecatheterTM)andleavethiscatheterinthetracheaafterextubation.Mostpatientswilltoleratethiscatheter.
• PostponeextubationandbringthepatientpostoperativelytoPACUorICU.
• Askyoursurgicalcolleaguestoperformasurgicalairwaybeforeextubatingtoprotecttheairway24,25.
Discussion
ThegoldstandardforthemanagementoftheexpecteddifficultairwayisconsideredanAFOIintheawakepatient26,27.Thefactthatthepatientisawakeisbothasignificantadvantageandapotentialdraw-back.Tomakethingscomplicated,thepatientisdoingallthethingshenormallydoes:breathing,movingswallowing,sneezing,andtalking.Thequestionis:whyisatechniquethatisconsideredthegoldstandardnotuniversallyusedevenwhenclearlyindicated?Oneoftheanswers:maintenanceoftheskillsthatarenecessarytomasterthistechniqueistoochallengingtomasteriftrainingorclinicalpracticeislimited,orinsufficientwhich,sadly,isinmanycountriesworldwidethenormratherthantheexceptiontotherule.AFOIcanbeconsideredasahighlycomplextaskthatrequiressoundtechnicalandmedicalknowledge,dexterity,goodcommunicationskills,leadershipandtheabilitytoworkunderpressure.IntheidealworldeveryanaestheticunitshouldhavepersonnelthatcanconfidentlyperformanAFOI.
Ininexperiencedhands,AFOIisoftenperformedwitholdequipmentunderstressfulconditionswhichisnotagoodformulaforsuccess.Indeed,AFOImaycertainlybeveryeasyifupperairwayanatomyisnormal,thepatientiscooperativeandupperairwayanalgesiaisgood.However,oftenanAFOIwillbeaccompaniedbyvariouschallenges.ForthesereasonsanaesthesiologistssometimestrytoavoidperforminganAFOIalthoughclearlyindicated.
AbriefwordonthepsychologyofAFOI
AFOIcanbeanextremelythreateningandinvasiveprocedurefromthepatient’spointofview.Nothavingthepatient’sconfidencefromthefirstmeetingtotheprocedureitselfwillresultinpoorconditionsfortheendoscopist,abadexperienceforthepatientandthetheatrestaffandfuture
reluctanceofbothpartiestorepeatthisprocedure,howeverclinicallyindicated.Keyistoengagethepatientsfromthefirstmoment,gaintheirconfidence,reassureatalltimesandneverlosecontactwiththemuntiltheyareasleep.Contactespeciallyduringtheproceduremustbemaintainedbysilencingtheunnecessarynoiseandchatterinthetheatreandfocusingyourpatientonyourvoice.Duringtheprocedurethevoiceoftheprimaryendoscopistsmustnotonlybetheonlyaudiblevoicebutmustalsoneverfallsilent.It’sinthesilencethatthepatientsmindisallowedtobuilddemonsorworstcasescenariosandtheendoscopists’risksrapidlylosingthepatient’scooperation.Thecontentoftheendoscopists“chatter”duringtheprocedureisnotthatcritical.Theoverallgoalistocalmandcomfortthepatient,tocomplimenthimoncooperatingandlastbutnotleasttoestimatethelevelofsedation.Itiscriticalthattheendoscopistschattertothepatientduringtheprocedure,whilethescopeisinthepatientsairway,isnotconstructedinsuchawaythatthepatientfeelstheneedtotalkbackoranswer–thiswilldynamicallychangetheairwaygeometry,causelossofviewandaddtimepluscomplexitytotheprocedure.Questionssuchas“howyoudoing?”withascopeintheairway,areneitherhelpfulnorproductive.
Sedationisacomplexarea.TheintentofsedationforAFOIistoincreasepatientcomfortandprovidesomedegreeofamnesia.Changeofsensoriumissometimestobediscouragedespeciallywiththepotentiallythreatenedairway.Rapidlyreversibledrugsarefarpreferableoverthosethatdonotprovidethe“getoutofjail”option.Havingtriedmostoptionsformanyyearsincluding(Fentanyl,Midazolam,FentanylandMidazolam,PropofolTCI,PropofolandFentanyl,Dexmedetomidine),wehavefoundthemtobemostlyunsatisfactorybecausetheonsettimeofthedrugsisnotfastenoughwhenasomewhatdeeperlevelofsedationisrequiredduringtheintroductionoftheETTthroughthenoseorglottis.Patientsaregenerallyover-sedatedandoccasionallyinadequatelysedated.Theover-sedatedpatientsdonotreversetheirlevelofsedationquicklyenoughtomakeanyofthesedrugsreallysafeinthissetting.ThedrugwhichforuscomesclosesttoourneedsforthissettingisRemifentanil.Anadvantageousside-effectofRemifentanilinthissetting,aswithallopiates,itthatitisanantitussive.Evenathigherlevelsandshouldthepatientbecomeoversedated,theyremainvoiceresponsiveandtheinfusioncanthenbereducedorstoppedwithrapidreturntopre-sedationsensorium.RememberthatRemifentanilalonedoesnotprovideamnesiafortheprocedure,aside-effectthatissometimesbeneficial,forexampleduringprolongedanddifficultintubationprocedures.We
recommendadultRemifentanilinfusiondosesof0.07–0.1micrograms/kg/min.Thesingleuseofremifentanilisprobablythebestsupporteddrugforthispurposeintheliterature,howeveritisnotwithinthescopeofthisarticletodiscussallthedrugs28,29Thedosageofremifentanilneedstobereducedfortheelderlyorthesystemicallyunwellpatient.InsurethattheRemifentanilinfusionislowconcentration–say20microgramspermlina50mlsyringe.Withthisconcentrationtherewillbeamoreconstantdrugdeliveryfromthesyringedriver.StarttheRemifentanilinfusion5minutesbeforetheactualendoscopy.Remifentanilcanbeadministeredincombinationwithpropofolinexperiencedhands,bothgivenasinfusion.Thesedrugsareshortactingorrapidlyreversibleandgivegoodanalgesia,sedationandamnesia.Howeverthereis,asstatedprevious,arelativelyhighincidenceofapnoeawhenusedincombination.AFOIseemsformanyclinicianstobeaverycomplextask.Itisverydifficulttosimultaneouslywatchamovingtargetthroughaflexiblescope,monitorandtalktoapatientandsedatehimaswellandcoachalltheotherpeopleintheatrewhoratherwouldimmediatelystarttheirsurgicallist.Whydon’twethen,forexample,performanAFOIwithtwoanaesthetistsasaroutinewheneverfeasible?Thisisnotcommonpracticeinmanyhospitals.OnlyafewofusaresuchskilledtechniciansandcommunicatorsthattheycandoanAFOIconfidentlyalone.Howmanyofusworkingatgeneralhospitalsperformmorethan5AFOIayear?Andhowmanyofustakeregulartrainingsessionsinafull-scalemedicalsimulatortoretaintheskillorrecertify?
Photo31
Dexteritytrainer
Photo32
Dexteritytrainercomponentsforscopetraining
Photo33
ORSIMTMmedicalsimulator
Conclusions
Inconclusion,donotlettheseincidentsdiscourageyoufromdoinganAFOIorspoilyourAFOIexperience.Mostincidentsorcomplicationsarepreventable.Whydon’tyoutrytobecomeoneofthedoctorswhocanperformanawakeflexibleintubationconfidently?Asdescribedinthisbook,foralmostallproblemsthereisasolutionandmostproblemscanbeprevented.
Finally,andthismaybeaveryhumblingexperience,donotforgetthatsomepatientscannotbeintubated,notevenbytheworld’sbestairwaymanagers.Rememberoxygenationwillsaveapatient’slife,notintubation.
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