Read and study books that describe awake
intubation techniques. There are a number
of different ways of doing this, and some people
like to do a superior laryngeal nerve block,
or a transtracheal block with local anesthetic
to reduce discomfort to the patient, and reduce
reflex activity. I personally do it
a different way, but it's,
it's not to say that my way is the right way,
but this is the technique that works for me.
So the first thing I do is, I get the patient
to gargle, usually 2% lignocaine lidocaine,
as long as possible. I want that, I nag at them
and nag at them to keep gargling.
And when they can't gargle anymore, they can swallow it.
And that has the property of creating some
local anesthesia in their, in their oral pharynx,
in the back of their throat. And some of it
may pass down through the cords and give them
some upper tracheal anesthesia as well.
Provide a little bit of sedation, usually
little bits of midazolam are sufficient.
Talk to the patient constantly, tell the patient
what you want them to do. Grasp
the tongue gently, usually with a gauze in your fingers,
and pull it forward as far as you can out of the mouth,
without causing the patient pain.
Dribble little bits of 1%
lidocaine over the tongue and down into the throat,
and have the patient breathe deeply. Tell them that
you really want big deep breaths. When the gag
reflex is lost, and this happens fairly
quickly actually, use your fiber optic bronchoscope
through the mouth, or through the nose, but
if you're going to use it through the nose, you have
to prepare the nose with a substance that
causes vasoconstriction, such as phenylephrine
or cocaine, which reduces the bleeding associated
with it. Before you pass the bronchoscope,
make sure you've loaded
a suitably sized endotracheal tube onto it.
When you see the vocal cords, stop.
Don't go through the vocal chords until you've injected
another 2 or 3 ml of 1% lidocaine through
the bronchoscope, onto the cords. The patient will cough.
But they'll cough once and then the cords will relax.
You'll then be able to pass the bronchoscope through the cords
without bothering the patient. Take it down as far as the carina,
where the two mainstem bronchi break away
from the trachea and, or from the larynx and
spray that as well. Patient will probably cough
one more time, and at that point, you're
ready to advance the endotracheal tube.
Sometimes it gets stuck at the, at the cords,
and you need to turn it a quarter turn to advance it.
But usually, you can advance it right down
the bronchoscope, into the patient's airway
and without a whole lot of trouble
at this point, and they're usually comfortable.
Take out the bronchoscope, inflate
the cuff on the, on the tube, hook up to your
anesthetic machine, and make sure that you're
getting CO2 back. So check your end-tidal CO2 monitor.
Once you're sure you're getting end-tidal
CO2 back, you know you're in the lungs.
You can then induce the patient and
start ventilating them. So in summary,
we've talked about
the anesthetic machine. The equipment we use
in anesthesia. We've talked about the monitors
that we use, both necessary monitors and monitors
that we can use according to our own judgment,
according to the condition of the patient. And we've talked
about the nightmare. The difficulty of intubating
a patient, particularly that frightening situation
where you can neither intubate, nor ventilate
the patient. From this, hopefully you'll be much better
prepared to deal with the airway problems
that are common in our population,
and successfully treat patients.