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Hi, My name's Keith Greenland.
I'm a fellow of the Australian and New Zealand College of Anaesthetists and also a fellow of the
Hong Kong College of Anaesthesiologists.
I received and MD from the University of Queensland
in April 2011
for my thesis based on a new approach to difficult airway management.
This particular film clip is one of a series I've produced based on the work of
doing over the last seven years.
This film clip is looking at
fibreoptic intubation
tips or tricks for the trade.
Awake fibreoptic intubation is one of the
techniques that is very
difficult to gain
experience with during training and maintaining the skill base during
professional life.
Mainly due probably to the exposure we have to suitable patients.
So there is now a problem of how to train our trainees
in this area and particularly
how to maintain those skills once trained
during a professional life.
This statement is quite relevant here I do believe...
Don't waste time learning the tricks of the trade instead learn the trade.
I've often seen advice being given during tearoom chatter
from experienced staff who
suggest one or two points out of their technique
which juniors take on
with a
fervour
thinking that this will be the solution to all their problems.
Really in the end,
training is actually a matter of putting in the time.
This talk is not going to go into bookwork detail
that's often read by people who are looking at such lectures as this.
What I would like to focus on are aspects of how I train
awake fibreoptic to my trainees
and in a way
looking at how to train the trainer.
There are three key aspects that I like to emphasise
dexterity
above all is important
sedation and local anaesthetic techniques are obviously
critical to this success
for awake fibreoptic, but
the dexterity requires
a certain amount of homework being done by the
trainee and by the practitioner.
There's no way of getting around it, there is no easy tips for dexterity
it is a skill that needs to be
trained up and maintained.
So
if we do
a very good, have got very good fine motor skills with our bronchoscope
then we find that sedation and local anaesthetic
techniques become less of an issue.
But let's focus therefore on dexterity initially,
and these are photos taken from the
Dexter workshop that we perform at the Royal Brisbane and Women's Hospital.
You can see the Dexter on the
left hand side that's been opened up, and you can see that it's a non-anatomical manikin
which is just basically a series of tubes with photographs of various things at the
end of the tube.
The program starts as module one, a very simple
module, with fairly easy
manoeuvring
skills required
as it goes through the modules the degree of
complexity of the passages
increases
and, to a point where you also get the
participant to stand in front of the manikin which turns everything
around the other way or upside down.
Each of our participants are broken up into pairs, the pairs have a got a bronchoscope and a
Dexter
and the pair works through the
training program.
One of the issues that I like to
address early on in the workshop
is the fact that we need to slow our participants down.
This belief that,
the skill with fibreoptics come along
and want to show off and they'd like to get down to the picture
very quickly,
but not infrequently some of these people actually
are hitting the
mucosa
the wall of the plastic tubes
quite regularly and this
must occur in their clinical
scenarios as well where they're hitting the patient's mucosa repeatedly.
They might be doing things quickly and getting the tube down quickly
but it is a failure if the
patient has been uncomfortable during the fibreoptic intubation
and refuses to have another fibreoptic
awake fibreoptic intubation again.
So speed is not the key,
indeed you really need to take things very slowly initially as a novice
and get the skills of just putting the bronchoscope in a centimetre or two
centring the image into the middle of airway so the tip of the bronchoscope
is in the middle
of the airway or the airway passage of the Dexter
and then moving the
tip further down by a centimetre or two again centring, so moving centring
moving and centring, very slow methodical
method teaches good skills.
It's obviously not to say that they the bronchoscope, the entire bronchoscope
is in the middle of the airway
that's obviously not correct, the rest of the bronchoscope is resting on the mucosa
behind the tip
but the patient with local anaesthesia and sedation tolerates the bronchoscope
sliding along the mucosa
quite well.
It's, what they don't tolerate
is having the mucosa constantly bombarded by the tip of the bronchoscope.
So if there is a whiteout
or a pink out
in the clinical scenario
the trainee should pull back
and start again and make sure they are in the middle of the airway at all times.
There is a number of bridging manoeuvres we perform these because the
bronchoscope workshops are often booked out
well and truly a year in advance or more
and therefore the lack of resources for teaching dexterity is, still remains a
problem.
So what I've devised is a number of bridging manoeuvres, that is
basically asleep fibreoptic
techniques,
so that both trainees and ancillary staff maintain their skill base.
This is the first of these bridging manoeuvres
this is on a patient after informed consent has been obtained
we're looking at young patients who are often coming to the head and neck
theatre for fractured jaws.
These patients require a nasal tube
so we anaesthetise them and put an LMA in
and ventilate
while the trainee
performs
the initial nasopharyngoscopy with the
fibreoptic and the tube is loaded on
they go through the nose they then go into the nasopharynx
get down to the pharynx and when they can see the LMA
the assistant removes the LMA, does jaw thrust
and the trainee
finishes the asleep fibreoptic
through the glottis and into the trachea.
So this not only provides a
rehearsal
for
maybe more difficult
awake fibreoptic
but it also helps the ancillary staff
learn how to set up the scope
initially and obviously also cleaning up afterwards. So this constant
exposure to the fibreoptic is not just for the trainee but the entire team.
The other bridging manoeuvre is the Aintree technique again after informed consent
from the patient
we may for instance in this case
after performing
an asleep
fibreoptic
during a research
project, and the patient has given consent
for this picture as well as being part of the research project.
The LMA is inserted, the Aintree and bronchoscope is inserted through the LMA
the bronchoscope is removed the LMA is removed and the tubes inserted over the
Aintree catheter.
This is a fairly low skill for fibreoptic intubations
probably this is why I've put it really as secondary to the first one
but it does
require the operator still
holding
bronchoscope and a certain degree of dexterity is involved
and like the previous one also makes the ancillary staff
required to set up the bronchoscope and clean it afterwards.
So as I've emphasised, this is really a team approach, it is not just all about
the operator, the team
also the support staff, the anaesthetic support staff
who get more and more comfortable as we do these
asleep elective
if you will, fibreoptic intubations become more and more comfortable about the setting
up and troubleshooting
when there are problems with the bronchoscope.
So how do you approach the patient? Psychologically
they need to be prepared well,
this is not something that people
are very trustful of when they first hear that they have to have an awake fibreoptic
especially if it's only minutes before the procedure.
I'd recommend strongly that patients are, receive informed
consent
as early as possible
prior to the procedure.
Oxygen is obviously essential this is a shared airway
The bronchoscope and the tube are in place at certain times, the
bronchoscope through the truth.
So there is problems with breathing particularly during the intubation
side of things
and on top of that obviously with the local anaesthesia
and the sedation obviously a degree of
oxygen is always required.
The essentials of setup.
This is prioritised to get to the
key issues first -
Focusing.
If you're using the eyepiece alone, there is focus ring on the eyepiece, with
the camera there is a second
focus ring on that.
I tend to just put the eyepiece one in the neutral position
the zero
and focus with the one on the camera.
The next is orientating the camera
this is very very important
the bronchoscope obviously cannot be driven
probably if it's not, the cameras not orientated correctly.
There is a notch at twelve
o'clock and that should be checked before starting
though I still in fact, double-check that usually by using the
some writing on the scope itself set up
to make sure that the camera is correctly
orientated on the eyepiece at all times.
The
common mistake that occurs with the setting up is that the camera
maybe zoomed out
and that's to say
we're looking at a very large image
what happens then is there is a mirror effect
where there is honeycombing of the image.
This is because the camera head
is actually
zooming in and there is a focus on the bundles, so you want to zoom out to eliminate
this, the image gets smaller
but the focus is then taken off the bundles and looking
further beyond the tip so you need to find the zoom
a ring which is usually immediately above
the focus ring
on the camera.
Obviously lubrication is critical,
lubrication of the fibreoptic,
before you put the tube and then lubrication of the tube
as well
sometimes operators may use a KY jelly or that type of
aqueous based lubricant.
This, if the setup is occurring in advance
the KY jelly may
actually dry out with air conditioning
in theatres
and what happens then is that the operator puts the fibre optic and
the tube down into the
trachea
and then has trouble actually removing the bronchoscope out of the tube.
As I said this is because probably the KY jelly has dried out to some degree
and there is a lack of proper lubrication
The best way to deal with this, is just drop a
couple of drops of saline, sterile saline inside the tube and that runs along
the bronchoscope down and reactivates the KY jelly.
There are many different types of sedation, this is one of the best studies
looking at this area
comparing the remifentanil and propofol
and
like everything there are proponents for
various
different concoctions.
In this particular study they looked at the Remi being easier for the endoscopy
and intubation
and certainly shorter
intubation times.
The recall obviously is worse, it's not as sedative as the propofol
but satisfaction overall is quite good, so it is horses for courses and I don't
believe that there is any perfect solution for this
type of procedure.
Atomising local anaesthetic into the nose and oral cavity
takes a couple minutes, I often do that in the induction room
prior to taking the patient into the theatre itself
various
concoctions may be used, ***
lignocaine and phenylephrine.
The phenylephrine being a very good vasoconstrictor
and avoiding hopefully the epistaxis.
After that I tend to put an epidural catheter down the working channel and drop
aliquots, 2ml of
2% xylocaine
down onto the vocal cords, a couple of
of those 2 ml aliquots and then go through the vocal chords
and spray another 2mls
in the subglottic space.
There is proponents of putting a tube, an endotracheal tube through the nose first
and then once you've inserted the tube then putting the fibreoptic through that.
Personally, and this is a personal view I've got some concerns.
The operators who feel that's worthwhile
feel that they get lost in the nose
and also they want to make sure that the endotracheal tube
will go through the nose
in the first place.
The concern I have
is that the tube will actually
cause
some bleeding if you keep on
if you do that every time and bleeding being a contraindication.
The other issue is the size of the bronchoscope and the size of the tube.
Basically,
the larger the bronchoscope the more likely it will hold its position
Small bronchoscopes as in this sort of situation
with a large tube particularly
the tube can be pushed
down and will go down into the oesophagus and pull
the bronchoscope out.
So we have a scenario where
the operator with a small bronchoscope and large tube
will go down with the bronchoscope to see the carina and then railroad the tube down
and have a lot of trouble, getting the tube in and finally also having trouble getting the
bronchoscope out of the tube
and then connecting up and there is no CO2
and yet they're positive that they saw the carina and this is what has happened
probably, they've actually peeled the bronchoscope out
and down into the oesophagus and the tube is actually oesophageal.
So
a larger bronchoscope say for instance the Olympus
LF - GP 4.1
is a quite good
size bronchoscope and
a tube say a 7.0 tube
fits very nicely into it and it's a reasonable tube.
There is various other types of bronchoscope though
from various
different makers, but we're looking at really
something around about the 4.1mm range for
awake fibreoptic.
Now the
railroading the tube, this is often a problem because the tip of the tube
of a normal PVC tube
picks up and attaches itself to the right arytenoid.
What you need to do is rotate the tube anticlockwise
the reason is because, first of all
you have to disimpact the tube first of all
you have to pull the tube back
it's often been pushed in
quite a bit
so you have to uncurl, straighten that tube out in the pharynx, so it needs to be
pulled back a few centimetres
and then disimpact, the tip needs to be disimpacted from the right arytenoid, so
it may sometimes need to be pulled back four or five centimetres before the tip
actually comes off the arytenoid.
And then it's a gentle rotation, now the rotation is ninety degrees
at the tip
so that the bevel is pointing backwards, you realise the bronchoscope is
resting along the posterior commissure so you bring the tip now into the middle of the
glottis and the bevel's resting against the posterior commissure so then it
slides over the posterior commissure and into the trachea.
There is a
a problem though with actually
rotating the tube because if you rotate it ninety degrees
approximately
the torsion in the tube may be lost and you won't get a full ninety degrees at
the tip. So I have a tendency just to
over rotate approximately and just gently insert it
so that you get finally a rotation of ninety degrees at the distal end.
And this is what we are trying to achieve this posterior facing
bevel.
There are other tubes which are very good for awake fibreoptic
for instance the Parker tip
on the left
this has actually got a posterior facing
bevel and also a tip that's curved in and hugs the
hugs the fibreoptic and tends not to get
caught on anything,
but is it available in the centre, and a lot of centres may not have these.
The other one is a fastTrach tube and again a very soft tube with a soft tip
a bevel that points
to left but the tip of the tube actually hugs the fibreoptic scope quite nicely
and is a very good tube, fairly ubiquitous in most centres where we do
anaesthetics
and a very nice tube to use.
There is, I've got a concern about some operators who I've seen who get the fibreoptic
in place, and see the carina and then want to anaesthetise the patient
while they put the tube in.
Now certainly the tube part, the fibreoptic intubation, as far as
putting the fibreoptic scopes concerned
you've done well, it's fairly painless to the patient and reasonably
comfortable,
it's putting the tube through the oral cavity or through the nose that
is probably the most uncomfortable part.
So some operators have got a tendency to put the patient to sleep.
This is a very hazardous manoeuver
because you're doing, I presume, an awake fibreoptic for a reason
and the tube may be caught on something and fail to go down
especially if the patient's anaesthetised with a loss of pharyngeal tone
the tongue falls back, the epiglottis falls back
more likely that things will get caught on the tube, so
I strongly recommend not
anaesthetising the patient
just because the bronchoscope is in the trachea.
So really in the end, the success of
awake
and asleep fibreoptic intubation
is
putting in the work.
The dexterity element is very critical.
The local anaesthesia as I said in the sedation aspects can be
less important
as the dexterity.
If you can't drive a bronchoscope well
it's going to be uncomfortable for the patient.
So success is not based
on whether you get the tube in,
but whether the patient accepts to have another fibreoptic again.
So get and do the dexterity workshops
and do the bridging manoeuvres
and I hope that this will help in the next awake fibreoptic.