Awake Fiberoptic Intubation (Rubin/Gurmukh)
There are many ways to do this; this section summarizes their approach.
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Medications → Midazolam and fentanyl only. These are reversible with flumazenil and naloxone respectively. While propofol/dexmedetomidine/remifentanil could be used, Rubin/Gurmukh argue against these agents since they are not reversible and may lead to a deep sedation state (dexmedetomidine leading to stage 2).
- Rubin also argues against glycopyrrolate, stating it takes about 30 minutes to see the anti-secretion effects.
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Topicalization → Rubin argues against nebulized lidocaine in the pre-op area for two reasons. 1, patient airway could become worse due to nebulization. 2, it does not work well with the small droplets unless patient airway is very dry, and it is not very effective.
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Rubin topicalizes heavily with a cotton tip wooden stick, lidocaine jelly, up the nares. Then nasal trumpet.
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ETT: Rubin prefers a 6–0 reinforced ETT, finds the tip to be sufficiently soft. Advance ETT through lubricated nares (after trumpet removed), park it about 8-10cm in. Advance scope through ETT.
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Scope → Rubin hooks up suction tubing to O2 and the scope so pressing down blows oxygen through. This helps oxygenate the patient and clear secretions.
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High flow nasal cannula → consider utilizing
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Once through, visualize the cords. Have paralytic on standby in case of laryngospasm. Advance scope through, then slide ETT through. Secure airway, go to sleep.
Rubin Injections → Argues for palpating at the thyroid hyoid ligament. Insert needle and aspirate for air (if aspirating air, the needle is in the vallecula). Pull back slightly until air is no longer aspirated; this indicates the thyroid-hyoid ligament where the internal branch of the superior laryngeal nerve is. Should feel like injecting into an eraser, give 2–4 mL of 2% lidocaine.
What about glossopharyngeal? Aim just posterior to the tonsillar pillar. Rubin finds this ergonomically tricky to do bilaterally with hand positioning. If injecting, remain very superficial. Advancing too deep may enter carotid vasculature.
What about superior laryngeal nerve? Aim for the greater cornu of the hyoid bone, but this can be difficult to palpate. Hence, Rubin’s preference on the thyroid hyoid ligament and having the local anesthetic track up the ligament to the nerve.
Bleeding Airway (Zuckerberg Bougie ETT)
ETT: Consider prepping with a bougie. Bougie enters first, and the ETT is preloaded (with the other end of the Bougie in the Murphy eye), then unhooked and advanced.
Suction in first, left side. Leave it in place. Then Video in → avoid contaminating camera or else visualization is compromised. Then ETT in.
Double Lumen Tube Insertion
and Sizing
Size appropriately if able by CT scan (outer diameter). Otherwise rule of thumb
is 39 Left for men, 37 Left for women (go up or down sizes if bigger/smaller).
Lubricate ETT thoroughly.
Once ETT in → bronch down bronchial lumen to guide into Left. Then bronch down
tracheal to confirm placement. Inflate tracheal cuff, leave bronchial down.
Position patient. Back down tracheal to confirm, then inflate bronchial cuff.
To secure → Tape tube and both ends of tape to the working side (use one strip, not two, so adjustment PRN is easier once positioned).
