Name: topical airway anesthesia for awake-endoscopic intubation using the spray-as-you-go technique with high oxygen flow
Uploaded: 2017-01-13T14:00:00
Description: Watch this Scientific Journal Video about Topical Airway Anesthesia for Awake-endoscopic Intubation Using the Spray-as-you-go Technique with High Oxygen Flow at JoVE.com

The authors have no acknowledgements.&#160;

All procedures were approved by the ethics committee of the medical association of the State Rhineland-Palatinate and performed in accordance with the Declaration of Helsinki.
1. Atomizer4
<ol>
	<li>Remove the set from package. Inspect the product to ensure there is no damage. 
	NOTE: The device is intended for one-time use. Please refer to the instructions for use for further information about storage and supply (see Materials and Equipment Table).</li>
</ol>
2. General Pre...

<ol>
	<li>Simmons, S. T., Schleich, A. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Airway+regional+anaesthesia+for+awake+fibreoptic+intubation.">Airway regional anaesthesia for awake fibreoptic intubation.</a> Reg Anesth Pain Med. 27, 180-192 (2002).</li><li>Benumof, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+the+difficult+adult+airway.+With+special+emphasis+on+awake+tracheal+intubation.">Management of the difficult adult airway. With special emphasis on awake tracheal intubation.</a> Anesthesiology. 75, 1087-1110 (1991).</li><li>Piepho, T., Thierbach, A. R., G&#246;bler, S. M., Maybaur, M. O., Werner, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+two+different+techniques+of+fiberoptic+intubation.">Comparison of two different techniques of fiberoptic intubation.</a> Eur J Anaesthesiol. 26, 328-332 (2009).</li><li>Pirlich, N., Lohse, J. A., Schmidtmann, I., Didion, N., Piepho, T., Noppens, R. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparison+of+the+atomizer+with+boluses+of+topical+anaesthesia+for+awake+fibreoptic+intubation.">A comparison of the atomizer with boluses of topical anaesthesia for awake fibreoptic intubation.</a> Anaesthesia. 71, 814-822 (2016).</li><li>Malcharek, M. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+the+Enk+Fibreoptic+Atomizer+with+translaryngeal+injection+for+topical+anaesthesia+for+awake+fibreoptic+intubation+in+patients+at+risk+of+secondary+cervical+injury:+a+randomised+controlled+trial.">Comparison of the Enk Fibreoptic Atomizer with translaryngeal injection for topical anaesthesia for awake fibreoptic intubation in patients at risk of secondary cervical injury: a randomised controlled trial.</a> Eur J Anaesthesiol. 32, 615-623 (2015).</li><li>Williams, K. A., Barker, G. L., Harwood, R. J., Woodall, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Combined+nebulization+and+spray-as-you-go+topical+anaesthesia+of+the+airway.">Combined nebulization and spray-as-you-go topical anaesthesia of the airway.</a> Br J Anaesth. 95, 549-553 (2005).</li><li>O'Hare, D. O., Harwood, R., Woodall, N., Barker, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+method+of+administering+topical+anaesthesia+for+flexible+airway+endoscopy.">A method of administering topical anaesthesia for flexible airway endoscopy.</a> Anaesthesia. 55, 616 (2000).</li><li>Long, T. R., Wass, C. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+alternative+to+transtracheal+injection+for+fiberoptic+intubation+in+awake+patients:+A+novel+noninvasive+technique+using+a+standard+multiorifice+epidural+catheter+through+the+bronchoscope+suction+port.">An alternative to transtracheal injection for fiberoptic intubation in awake patients: A novel noninvasive technique using a standard multiorifice epidural catheter through the bronchoscope suction port.</a> Anaesthesiology. 101, 1253 (2004).</li><li>Xue, F. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spray-as-you-go+airway+topical+anesthesia+in+patients+with+a+difficult+airway:+a+randomized,+double-blind+comparison+of+2%+and+4%+lidocaine.">Spray-as-you-go airway topical anesthesia in patients with a difficult airway: a randomized, double-blind comparison of 2% and 4% lidocaine.</a> Anesth Analg. 108, 536-543 (2009).</li><li>Hershey, M. D., Hannenberg, A. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Gastric+distension+and+rupture+from+oxygen+insufflation+during+fiberoptic+intubation.">Gastric distension and rupture from oxygen insufflation during fiberoptic intubation.</a> Anesthesiology. 85, 1479-1480 (1996).</li><li>Ho, C. M., Yin, I. W., Tsou, K. F., Chow, L. H., Tsai, S. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Gastric+rupture+after+awake+fiberoptic+intubation+in+a+patient+with+laryngeal+carcinoma.">Gastric rupture after awake fiberoptic intubation in a patient with laryngeal carcinoma.</a> Br J Anaesth. 94, 856-858 (2005).</li><li>Chapman, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Gastric+rupture+and+pneumoperitoneum+caused+by+oxygen+insufflation+via+a+fibreoptic+bronchoscope.">Gastric rupture and pneumoperitoneum caused by oxygen insufflation via a fibreoptic bronchoscope.</a> Anesth Analg. 106, 1592 (2008).</li><li>Ovassapian, A., Mesnick, P. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Oxygen+insufflation+through+the+fiberscope+to+assist+intubation+is+not+recommended.">Oxygen insufflation through the fiberscope to assist intubation is not recommended.</a> Anesthesiology. 87, 183 (1997).</li></ol>

Here we demonstrate topical anesthesia using an atomizer with high oxygen flow for awake-endoscopic intubation. The first study to evaluate the atomizer technique compared it with classical boluses of topical anesthesia via the working channel of the flexible intubating endoscope5. Patients in the atomizer group evaluated their level of comfort as better than those in the control group and experienced fewer coughs and distinct coughing episodes. In addition, the atomizer technique was faster and less local ane...

Topical anesthesia of the airway for awake intubation is generally recommended to improve patient comfort, which will help make the procedure a success. The spray-as-you-go technique with high oxygen flow is a simple and safe concept that is finding a high level of acceptance among patients. The atomization of the local anesthetic by oxygen at a flow rate of 10 L/min results in less stimulation of the cough and gag reflex.
Faced with negative feedback from several patients, we decided to refine the standard institutional spray-as-you-go technique. This classical bolus application of local anesthetic consisted of two injections, each of 5 mL lidocaine 2% plus 5 mL air in a 10 mL syringe, first into the vocal cords and then, after a 2-min waiting time, into the trachea. Patients complained about the feeling of being drowned by the splash of the bolus striking their airway mucosa.
The spray-as-you-go technique is commonly used worldwide1. This technique involves local anesthetic application through the working channel of a flexible intubating endoscope while advancing the tip through the upper and lower airway with the goal of intubating the patient&#180;s trachea. There are multiple approaches in practice and several descriptions of methods in the literature. Initial experiences with the spray-as-you-go-technique in combination with application of a constant oxygen flow through the working channel were published in the 1990s2. The focus here was on oxygen flow effects like cleaning the lens by dispersing mucus secretions and blood away from the lens and elevating the inspiratory oxygen delivery. The advantage of the oxygen flow in aiding atomization of local anesthetic was shown previously by Piepho and colleagues3. They described a vaporization technique, where the supply of 3 L/min oxygen resulted in less coughing by the patients. On the assumption that a flow of 10 L/min would atomize the local agent into finer particles that would evoke even less coughing, we successfully tested the atomizer at this higher flower rate. The atomizer consists of a small volume, kink-resistant, flexible, pressure-certified oxygen tube and a connecting tube. These are connected to a three-way sidearm fitting with a small flow-control opening.
The atomizer technique can be used for all airway situations. However, the device should be used cautiously distal from higher-grade airway stenosis caused by conditions such as tumor masses. The lack of backflow of oxygen could cause increased airway pressure and increases the risk of barotrauma. Also, the atomizer is a useful tool in an emergency setting. The preparation of the set needs less than a minute and the user needs no special training. In the following we present detailed operating instructions for the spray-as-you-go technique with high oxygen flow, illustrating the separate working steps.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Lidocaine 10% pump spray&#160;</td>
			<td>e.g. AstraZeneca</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Opiod for i.v. administration</td>
			<td></td>
			<td>Any opiod can be used. We prefer either Sufentanil or Fentanyl</td>
		</tr>
		<tr>
			<td>Enk Fiberoptic Atomizer Set&#160;</td>
			<td>Cook Medical</td>
			<td>Catalogue number: C-EFNS-100&#160;</td>
		</tr>
		<tr>
			<td>Lidocaine 2%&#160;</td>
			<td>e.g. AstraZeneca</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Intubation endoscope</td>
			<td>e.g. Karl Storz Endoscope</td>
			<td>We prefer a fibrescope with an outer diamter of 5 mm and a working channel with a diamter of 2 mm&#160;</td>
		</tr>
		<tr>
			<td>Endotracheal tube</td>
			<td>e.g. R&#252;sch</td>
			<td>Size of the endotracheal tube needs to be adjusted to the patient. We prefer a ID 6.5mm for nasal approach and ID 7.0 mm for oral approach</td>
		</tr>
		<tr>
			<td>Anesthetic drug, e.g. Propofol 1%</td>
			<td>e.g. AstraZeneca</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

topical airway anesthesia for awake-endoscopic intubation using the spray-as-you-go technique with high oxygen flow

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can jeopardize their spontaneous breathing, topical anesthesia of the airway is a popular technique. The spray-as-you-go technique represents one of the simplest opportunities to anesthetize the airway mucosa. The application of local anesthetic through the working channel of the flexible endoscope is a widespread practice for anesthetists as well as pulmonologists. There is neither need for additional devices nor special training as a pre-requisite to perform this technique. However, a known clinical problem is the coughing and gagging reflex that may occur when the liquid anesthetic strikes the airway mucosa and other sensitive structures like the vocal cords. This can be avoided by the use of oxygen applied through the working channel with the aim of fogging the local anesthetic into finer particles. Furthermore, the oxygen flow provides a higher oxygen supply and contributes to a better view, dispersing mucus secretions and blood away from the lens. Using an atomizer with a high oxygen flow of 10 L/min we maximized these benefits, caused less coughing and had more satisfied and therefore cooperative patients. Possible, but very rare complications of using oxygen flow including gastric insufflation, organ rupture or barotrauma did not arise. We attribute the complication-free use of high oxygen flow to the design of the set, which permits flow and pressure release.

We performed awake flexible endoscopic intubation using the presented topical anesthesia technique in 48 patients. We succeeded in intubating all patients except one, who suffered from a stenosing tumor of the pharynx, which made it impossible to advance the tube.
The quality of awake intubation comfort was evaluated by patients, anesthetists and nurses using an 11-point visual analog scale (VAS) from 0 = not unpleasant to 10 = ...

Watch this Scientific Journal Video about Topical Airway Anesthesia for Awake-endoscopic Intubation Using the Spray-as-you-go Technique with High Oxygen Flow at JoVE.com

Topical Airway Anesthesia for Awake-endoscopic Intubation Using the Spray-as-you-go Technique with High Oxygen Flow

The topical anesthetic lidocaine was atomized using a high oxygen flow through the working channel of a flexible intubating endoscope to achieve topical airway anesthesia for awake endotracheal intubation. We prefer this modified spray-as-you-go technique for endoscopic intubation to classical bolus application because of higher patient satisfaction and better compliance.

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can ...

The overall goal of the spray-as-you-go technique is to provide sufficient topical anesthesia during intubation with higher patient satisfaction and better compliance than the classical bolus application of anesthetics. The main advantage of this technique is that the oxygen flow atomizes the local anesthetic into fine particles, which evokes less coughing and therefore patients are more satisfied and cooperative. We had the idea for using this method when we were struck by the patients complaining that the splash of the bolus striking the airway mucosa gave them the feeling of being drowned.To begin, apply a one milliliter mixture of two percent lidocaine with 0.25%phenylephrine to each nostril. Then, apply a local anesthetic such as by spraying 10%lidocaine directly onto the mucosa of the oral pharynx twice from the tip to the back of the tongue. Ask the patient to gargle the lidocaine for as long as possible.In preparation, have ready an inspected, undamaged atomizer ready for its intended one time use. Assemble and check a flexible intubation endoscope and then railroad a suitably sized cuffed and lubricated flexible endotracheal tube over the endoscope. Then, connect the oxygen tube of the atomizer directly to the oxygen flow meter without a humidifier bottle, as they are incompatible with the atomizer.Next, attach the connecting tube from the atomizer to the lower tape on the working channel of the endoscope. Then set the oxygen flow rate to 10 liters per minute. Now, connect a one milliliter syringe containing two percent lidocaine to the three-way side arm fitting and proceed with the technique.The challenge of this technique is the correct execution of delivering the lidocaine to the atomizer. Closing and releasing of the pressure control channel have to be properly timed. First, deliver the prepared dose of two percent lidocaine to the atomizer while closing the flow control opening by finger and rapidly injecting the medication.Then, immediately release the flow. The use of a high oxygen flow allows fogging of the local anesthetic into fine particles. Now begin advancing the flexible endoscope in the airway while injecting the local anesthetic via the atomizer along the inside of the nostril, along the posterior nares, the epiglottis, the glottis, and the vocal cords.Before passing the endoscope past the vocal cords, wait two minutes for the anesthesia to take effect. Next, advance the endoscope carefully through the glottis into the trachea, and position the tip just above the carina. Be careful to not advance to the main stem of the bronchus.Railroad the tube into the trachea using rotation. Now remove the endoscope, leaving the endotracheal tube in place. The described awake flexible endoscopic intubation was successfully performed on 47 of 48 patients, barring one who suffered from a stenosing tumor of the pharynx.On an 11 point scale from not unpleasant to intolerable, the patients rated the experience as a one and the hospital staff rated it a two. Overall, the procedure was well-received. In addition to these vital parameters, the main duration of the intervention was five minutes and the average amount of 2%lidocaine atomized during was 100 milligrams.The median number of coughs in a control group using the classical bolus application of two times five milliliters two percent lidocaine, was nearly twice as high. Once mastered, the technique can ease and accelerate the procedure of awake fiber-optic intubation. It must be considered that the attended time heavily depends on the expertise of the operator and the level of difficulty of the patient's airway.A major challenge is to ensure that the procedure is comfortable for the patient in order to enable optimal intubation conditions, while the patient continues to breathe spontaneously. The atomizer is a useful tool in an emergency setting. The preparation of the set needs less than a minute, and the user needs no special training.It might also be a valuable feature to facilitate endoscopic bronchoscopy. Don't forget that working with a constant oxygen flow includes potential complications, like gastric insufflation, organ rupture, and bowel trauma. By using the flow control opening of the atomizer, these complications can be avoided.

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