awake intubation for subglottic stenosis

[Carlos Danger]

Not all that related to prehospital airway management, but I thought some of you might find this interesting.

The subglottic stenosis that can be seen at about 5:00 min is pretty impressive.

https://www.facebook.com/video.php?v=1227276124011378

 

[VentMonkey]

Very cool video, @Remi. I almost brought up awake intubation and criteria in another thread, so I am glad you shared this. Aside from these types of patients, who in-hospital would most likely be a candidate for this procedure?

This stenosis seen at ~5:00 is applicable to any airway management provider, though you are correct, this particular procedure is by no means something that should be clumped into prehospital airway management.

The fascination I have with airway management in all fields would include something of this nature, though.

Also as a side, that "Airway EX" app I mentioned (also in another thread) gives case scenarios like this, and even allows CME's (I don't think for paramedics since it's again, not something we routinely do), and was created by an anesthesiologist.

 

[EpiEMS]

Not all that related to prehospital airway management, but I thought some of you might find this interesting.

The subglottic stenosis that can be seen at about 5:00 min is pretty impressive.

https://www.facebook.com/video.php?v=1227276124011378

Quite the video there!

Curious - is there a preferred technique for anesthetizing the airway ("topicalization of the airway", I think, is a term for this)? I've seen a couple of different techniques used - nebulized lidocane, spraying lidocaine on the mouth/throat, etc. - but is there anything that's "gold standard"?

and even allows CME's (I don't think for paramedics since it's again, not something we routinely do),

I think that some states allow you to use non-EMS CME - CT does, for sure. I'm not sure if Registry does, but I don't see why they *ought* not.

 

[Carlos Danger]

I have very little experience with FOI. Nova1300 can probably talk much more intelligently about it than I can. At work we keep talking about starting to do them more for practice, but in a fast-paced practice the logistics of that are difficult.

Before VL became commonplace, FOI was the standard of care for any intubation that was anticipated to be very challenging. Now it is mostly reserved for situations where anatomy is really distorted and taking away respiratory drive could be disastrous (such as a mediastinal mass or subglottic stenosis), which is why so many of us these days have so little experience with it, especially if you don't work in a tertiary center.

There are lots of different "recipes" for keeping a patient breathing but comfortable during the procedure. Some, like in this video, focus on topical anesthesia and keep sedation to a relative minimum, some utilize nebulized lidocaine or nerve blocks, and still others go the other way and don't rely a lot on local anesthesia but more on sedation. I've had pretty good luck a few times doing awake VL with benzocaine spray, versed, and small doses of fentanyl.

 

[EpiEMS]

There are lots of different "recipes" for keeping a patient breathing but comfortable during the procedure. Some, like in this video, focus on topical anesthesia and keep sedation to a relative minimum, some utilize nebulized lidocaine or nerve blocks, and still others go the other way and don't rely a lot on local anesthesia but more on sedation. I've had pretty good luck a few times doing awake VL with benzocaine spray, versed, and small doses of fentanyl.

I see - thank you for the clarification - I imagine it must vary by patient, too. I would think that some patients require anxiolytics, say, while others are OK with just the topical anesthetics.