Patient-controlled anesthesia for the upper airway can be an effective strategy to prepare patients for awake intubation, a recent study has found.
A 2% lidocaine “lollipop” helps patients cooperate using an easy, inexpensive and readily available means, the researchers said.
“We recognize this technique doesn’t ensure directed local anesthetic application and requires additional topicalization techniques,” said Kathryn Sparrow, MD, assistant professor of anesthesia at the Memorial University of Newfoundland, in St. Johns, Newfoundland and Labrador. Dr. Sparrow presented the research at the 2016 annual meeting of the Society for Airway Management, and acknowledged her colleague Orlando Hung, MD, from Dalhousie University, in Halifax, Nova Scotia, for studying the technique.
“My colleagues and I have performed more than 20 patient-controlled topicalizations with good acceptance and effectiveness,” she said.
2 Tough Cases Reviewed
Dr. Sparrow discussed two cases using this technique. In one, a disposable foam oral swab soaked in a viscous 2% lidocaine solution was given to an obese patient with a body mass index of 40 kg/m2 and a history of difficult bag-valve-mask ventilation and use of a laryngeal mask airway. The patient cooperated with the topical anesthesia and underwent awake intubation with a flexible bronchoscope without gagging or coughing during tracheal intubation.
“The patient could stop the topicalization procedure if he felt he might gag or cough and could control the amount of pressure exerted on the tongue,” she said.
In the second case, the patient had ankylosing spondylitis and a cervical spine fracture sustained in a traumatic fall. He underwent multiple awake intubations for previous surgical procedures and had significant coughing episodes during those intubations. The limited cervical spine movement and instability prevented local anesthetic gargling. The patient received the lidocaine-soaked swab, oxymetazoline spray and atomized lidocaine, and underwent awake intubation with a flexible bronchoscope without gagging or coughing.
“This technique eliminates the need for gargling, which can be difficult for many patients to perform,” she said. “It can help patients with limited cervical spine movement or instability, externally applied devices such as halos or required use of the supine position.”
Anesthesia providers report 23% of patients cough or gag during awake intubation, and almost half of failed intubations are related to inadequate topicalization with coughing, gagging or vomiting, she said.
“Attempts to facilitate cooperation with patients are warranted,” Dr. Sparrow said. “Despite low failure rates of 1% to 2%, suboptimal airway anesthesia remains a significant contributor to complications from awake intubation.”
Dr. Sparrow and her colleagues hope to conduct future studies with larger numbers of patients to confirm the usefulness of the technique