Awake intubation with the GlideScope can be an especially helpful technique when intubation of a difficult airway under direct vision is optimal. One of the most challenging scenarios to face is a tumor in the airway. Working closely with your surgeon is important. In this particular case, we actually had a video available of what this 8 mm airway polyp looked like popping in and out of a laryngeal opening of about the same size with each breath like a potential cork. According to the surgeon our patient had come to the clinic because she had been experiencing some increased shortness of breath. Having the video was a rare advantage. Follow this link to youtube video showing pedunculated vocal cord polyp obstructing the glottic opening. Here are some stills from that video.
Photo of pedunculated laryngeal polyp in lowest position below vocal cords at end of inhalation
Photo of pedunculate laryngeal polyp being expelled between vocal cords during exhalation
Photo of pedunculated laryngeal polyp at its furthest position above the vocal cords at the end of exhalation
My surgeon recognized that we needed to strategize together to come up with an optimal plan. He needed a smaller than average tube size to allow him to operate on the polyp. He was also worried this might be fragile tissue, easy to bleed. However he felt certain that if I anesthetized her in the normal fashion I would be able to intubate with normal laryngoscopy.
However, I worried that if I did paralyze her for induction and failed to intubate, that I might not be able to ventilate her. The polyp might plug the trachea with manual ventilation.
If I did an awake fiberoptic intubation with the patient breathing, I would be able to pass the fiber into the larynx under direct vision. Unfortunately, I would then have to pass the endotracheal tube down the fiber blindly over the fiber. In the worst case scenario, the tube could catch on the polyp, rip the polyp off its stalk and shove it down the trachea — causing bleeding and perhaps airway obstruction down at the carina.
I decided to perform awake i intubation with the GlideScope. A GlideScope doesn’t require as much jaw lift as conventional laryngoscopy. This would allow me to pass the tube under direct vision with the patient awake as long as she was well topicalized. The surgical team would also be able to see and comment on the intubation in progress. The surgeon stood by with his tracheostomy equipment nearby just in case things did not go as expected.
After pre-treatment with glycopyrrolate to dry secretions, and some slowly titrated midazolam and fentanyl, I topicalized her oropharynx with local anesthetic spray. I then performed glossopharyngeal nerve blocks to block her gag reflex. I also explained to the patient throughout what she would experience so that there were no surprises that might cause panic.
Using the GlideScope to visualize the larynx, and timing my forward insertion of the tube into the larynx to when the polyp was visible above the cords, I easily passed a 6.0 mm endotracheal tube. We then induced general anesthesia.
There are many different ways to have safely intubated and anesthetized this patient.The important point was that the surgeon and I discussed the concerns and together came up with a plan. We also had plans for what we would do if we lost the airway.
Although usually used to intubate the patient under general anesthesia, the Glidescope can be used for awake intubation. Using the same preparation as for fiberoptic intubation was quite effective and left open the option of switching to fiberoptic intubation should the attempt with the GlideScope have been unsuccessful. The patient tolerated the procedure well.
In these days of advanced technology, we often avoid awake intubate because of concern of causing the patient pain or distress. However, sometimes awake intubation is the safest way to proceed and if you are gentle and prepare the patient well, it can be comfortable as well. Awake intubation with the GlideSope is just another tool you can use for difficult airways.
For further discussion of intubation technique using the GlideScope, or when to use awake intubation click the links below:
- GlideScope: Tricks For Successful Intubation
- GlideScope Technique For Intubation In Small Mouths
- Anticipated Difficult Intubation: Should I Intubate The Patient Awake?
May The Force Be With You
Christine Whitten MD,
author: Anyone Can Intubate: A Step by Step Guide, 5th edition
and
Pediatric Airway Management: a Step by Step Guide
Click the covers to see inside the books at amazon.com
I note your reasonable concerns, preoperative planning (great to have that video and consultation), double set-up preparation, and your “burn no bridges” approach. Kudos to you and to ENT. You also said that are “many different ways to have safely incubated.”
Might a possible fail-safe option have been to do a preemptive small-bore cricothyrotomy for potential jet oxygenation/ventilation rescue? Retrograde flow from that cannula might even flip up the cork of the 8mm polyp separating the tissues for a bougie. If all had gone bad, High-Frequency Jet Ventilation could be done for a motionless chest after induction and paralysis to permit meticulous work by ENT. Again, kudos to you both. I understand their confidence in intubation carries great weight, but also appreciate that a friable pedunculated polyp is great cause for concern.
Thanks for pointing out the typo. I must have been channeling my Dad, who has yet to learn how to pronounce intubate. Using a preemptive cricoid catheter for jet ventilation would have been a fine safety precaution. In this case I did have the advantage of the video as well as knowledge that the patient had pretty good exercise tolerance as well as the ability to lay flat fairly comfortably. Plus I had the video and planned an awake intubation. However I hadn’t thought about the fact that I could “blow” the polyp above the vocal cords and perhaps keep if there. That’s a good suggestion. Jet ventilation is indeed a good technique to remember and one which is often forgotten until a crisis is reached. It’s also a technique that can get you into trouble with complication such as pneumothorax and subcutaneous emphysema if you are incautious. I will talk about this in a future article. Thank you for your comments.
Fascinating meticulous approach Dr Whitten, to me it illustrates a thoroughly thought out method. Specificity and finesse which seems to be lacking nowadays.
I am very skeptical about the fad, like approach to VL especially having seen a case where fundamentals like positioning are ignored “because ‘VL’ ” watching the patient lagg worthy sats below 70 for far too long, because the ETT was hitting the right aretenoid. It takes skill practise and supervision to adjust to new devices.
Thanks for the teaching