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Airway anesthesia Dr Amit Shah

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Transcript of Airway anesthesia Dr Amit Shah

Bougie is part of plan A
Difficult airway society guidelines
Narrow diameter tracheal tube introducer with an outer diameter of 5 mm

The original design (reusable version) is made of beige colored resin covering a  fiberglass core.
Length- 60 cm,
Caude tip- tip bends at 38 degrees

Essential feature is Flexibility with shape retention capacity

GEB - misnomer
Eschmann stylet- Bougie
Solid vs hollow ( with or without stylet)

Length vary- 50, 65,68 70, 100 cm.

Diameter 8 Fr - 19 Fr (2.5mm-6.5mm)

Pediatric version is also available- 2.5 mm, 35 cm

Indian reusable version are made up of pvc material

Marking are available from tip

All solid bougie are flexible with shape retention capacity

Hollow Bougie can be used as airway exchange catheter, where oxygenation is possible
Now many version available
With flexibility with shape retention capacity- do not need to align the angle
and smaller diameter

Tube with stylet-
has fixed shape and angle- you need to keep all angle and alignment proper
Larger diameter of tube
Uneven shape of stylet
Why do we need them
when we have stylet ??????
Two person technique vs. One person technique
Kiwi grip
Single person technique
Here Bougie is introduced in trachea
Assistant need to stabilize the other end of bougie
Assistant then mount the Endotracheal tube over distal end of bougie
Two person technique
After doing laryngoscopy boogie should be glided beneath the epiglottis in midline if you are not able to see any other glottic structure.

Confirmation of tracheal entry-
You may feel the tip bouncing of the tracheal ring
It stops advancing once 25-40 cm mark has reached as narrow airway
Laryngoscope removal after placing bougie in larynx-
may cause tongue & pharyngeal structure to fall down , this will cause difficulty in introduction in ET tube.
The assistant glide the ET over boogie and once it enters the oral cavity you can take over and ask him to hold the end of boogie
As you slide the boogie in this will be concavity toward the ceiling, as you reach near the larynx sliding further may become difficult because of step created between the boogie and ET
Turn boogie counter clock wise direction for 90 degrees. this will reduce the step and allow easy passage for antero-posterior wide area in to larynx.
Counter Clockwise Rotation
a key feature
Step Created Because Of
Difference In The Outer Diameter Of Bougie And Inner Diameter Of Tube
Counter Clockwise Rotation To Avoid Difficulty

To avoid this problem altogether you can use parker flexi-tip tube , or tube for the intubating lma which has tip which is a atraumatic and it remain in close contact with the boogie.
Bougie guide Intubation through LMA
Indian PVC verison
Cook Frova tube introducer with stiffening cannula
Airway exchange caheter
Rapifit Adapter
Gum Elastic Bougie
Inutubating stylet
Tube introducer
Airway exchange catheter
Narrow diameter tracheal tube introducer with an outer diameter of 5 mmThe original design (reusable version) is made of beige colored resin covering a  fiberglass core. The total length of the original version is 60 cm and the distal tip bends at an angle of  38  degrees. Essential feature is Flexibility with shape retention capacity
Indian PVC verison
Bougie-With flexibility with shape retention capacity- and smaller diameter allow it to pass beyond vocal cord without difficulty even in absence of alignment of various angels.Tube with stylet- has fixed shape and angle- you need to keep all angle and alignment proper to introduce tubeLarger diameter of tube hamper the entry beyond vocal cordUneven shape of stylet makes removal of stylet sometimes difficult.
Railroading of Tube over Bougie
Counter clockwise rotation of tube at laryngeal inlet
Keep laryngoscop inside while introducing ET
Simulated difficult intubation.
Comparison of the gum elastic bougie and the stylet.
Gataure PS, Vaughan RS, Latto IP.
Anaesthesia. 1996
After two attempts the tube was correctly placed in the trachea in 96% of cases in the Bougie First Group compared to only 66% of cases in the Stylet First Group (p < 0.001)
How many of you have bougie always available in the OR ??

stylet ???

Bougie ???
What is first choice??
Survey of the use of the gum elastic bougie
in clinical practice
I. P. Latto, Anaesthesia, 2002

Successful difficult intubation. Tracheal tube placement over a gum-elastic bougie.

Dogra S, Falconer R, Latto IP
Anaesthesia. 1990 Sep;45(9):774-6.
Keep the laryngoscope inside we have a reflex to remove the laryngoscope once we introduce the boogie in larynx, but it should not be done because removal may cause tongue & pharyngeal structure to fall down , this will cause difficulty in introduction in ET tube.
Airwaycam.com - tube introducer page
Confirmation of successful larynx introduction
15 Fr, 70 cm
4 mm, 65cm
14 Fr, 19 Fr
90 cm
original bougie
Survey of the use of the
gum elastic bougie in clinical practice
I. P. Latto, Anaesthesia, 2002
Infection with reuse
Bougie breakage
Pharyngeal perforation and oesphageal lacertion
Latto p- fracture of varnish layer of GEB anesthesia 1999
Gardener M - detachment of tip of GEB - Anesthesia 2002
Kadry M - pharyngeal wall lacertion
Prabhu A- reported pneumothorax
Gum Elastic Bougie–guided Insertion of the ProSeal
Laryngeal Mask Airway Is Superior to the Digital and Introducer Tool Techniques
Joseph Brimacombe, M.D. Anesthesiology 2004;
Other usage
Large ambient light

Thick , short neck and dark skinned patients

In very thin patient, a oesophagial placement still gives you glow

Contraindicated in known anatomical abnormalities of the upper airway (tumors, polyps, infection, foreign body etc
Where neck mobility is restricted or contraindicated
Where to use it
Anesth Analg 2000
Lionel Davis etal
Review article
Lighted stylet tracheal intubation: A review
the same principles apply as oral with the following additions.

Topical nasal vasoconstrictor and local anestheticapplication

Shape the stylet according to patient profile

Lubrication is between tube and stylet for smooth slide
Difficulty advancing the ETT

Stylet may be stuck in the vallecula, giving impression of a pre-tracheal glow:
Withdraw and re-advance more posteriorly.
jaw lift or tongue may help

The ETT is getting stuck on the vocal cords:
Withdraw and re-advance,
change to smaller diameter ETT
Use ILMA tube or Parker felxitip tube..

Troubleshooting Tips
Darken the OR

Regular position, - side position

Midline insertion or from angle of mouth

Jaw lift or tongue pull

Identify the pretracheal glow

Advance the ETT
Oral Intubation
Select smallest size of ET tube

Remove the connector

Lubtricant jelly for smooth movemnt of ET Tube

Tip just inside the tip of ETT.

Check the light wand light
inAirway management: How current are we?
Venkateswaran Ramkumar

Adjuncts to facilitate conventional laryngoscopy and intubation
The majority of responders (close to 80%) opined that the lighted stylet was not a device that they would reach out at CICV.
Light wand
The journal of international medical research 2012 J Chen etal

Optimal bend length- randomized, prospective comapritive study-
“hockey-stick” formation
Bend the ETT/lighted stylet assembly to a sharp angle > 90 degrees.
For Oral And Nasal Intubations
In Both Asleep And Awake Patients
Adult and Paediatric patient
Anesthesiology 1986
Guided orotracheal intubation lighted stylet and laryngoscopy comparison
Ellis et al
99 % success rate in experienced hand
Lighted Stylet Guided Intubation Can Be A Useful Technique
Can J Anaesth 1997
Hung OR
Light guided Retrograde intubation in cervical instability patient
J Clin Anesth 1998
Agro F etal
Claimed 100 % success rate of intuabtion through LMA
Anesthesia 1997 Biehl JW
LW improve light and glow helps in confiming tube pessage
Laryngoscopy with light wand

Trachlight can be passed through the LMA to assist in intubation

Light-guided Retrograde Intubation-
use of a lighted stylet placed at the tip of the endotracheal tube, which will then guide tube advancement over the catheter

With FOB or Airway Introducer
Hybrid techniques
Malleable stylet with bulb and tube holder
Internal or external light source

lighted stylet with flexible fiberscope
Optical-audio feedback system
Most under utilised airway tool.
just proximal to the cuff
patient's thyroid cartilage
to the angle of their mandible
or incisor
Two different approaches are taken in determining the location of the bend of the ETT/lighted stylet assembly.
246 patient and studied the optimal length- gender based where bent beyond cuff least timing, and optimal bent length in adult 6-6.9cm
Orlando Hung- remarkeble
study over 2 yrs- 206 patient expected difficulty intubated all but 2 and 59 patient predicted easy but failed intubation - all were intubated successfully by light wand,
failed laryngoscopy patient were intubated by experieced in lightwand anesthetist
Mary waincott reviewed the literature for the comparison of cervical spine movement in various devices and techniques- result- laryngoscopy, mask ventilation maximum motion- followed by glidescope and other vl but least by lightwand and FOI
Restricted mouth opening-
6-8 mm sufficient
a bloody airway, (lighted stylet has no optical viewing element.)
Emergency intubation using a light wand in patients with facial trauma
J Emerg Trauma Shock. 2009 Jan-Ap
Sandeep Sahu, et al
Department of Anaesthesiology, GSVM Medical College, Kanpur, UP, India
Use of the Lightwand (Trachlight-TM) as an Aid to Tracheal Intubation in Patient with Limited Mouth Opening and Failed Macintosh Laryngoscopy
The Internet Journal of Anesthesiology
Case Report Of A 48 Year Old Male With Multiple Facial Fractures Due To An Attack By A Wild Bear
Ushma Shah M.B.B.S
K.E.M. Hospital and Seth G.S. Medical College
Mumbai India
Anticipated / unanticipated or even failed direct laryngoscopic intubation
Lightwand: a useful aid in faciomaxillary trauma
Stuti Jain, Umesh Bhadani
j of anesthesia apr 2011
gunshot wound
gas cylinder burst
wolf attack
Gangrene of upper lip
Ankylosing spondylitis
Lightwand-Assisted Nasotracheal Intubation in Awake Ankylosing Spondylitis
Thida Uakritdathikarn MD et al
J Med Assoc Thai 2006
various case reports
Can J Anaesth. 1995
Lightwand intubation: II--Clinical trial
Hung OR etal
Review of literature to determine techniques which produces least cervical spine movement:
Mary Beth Wainscott -
Lightwand-Assisted Nasotracheal Intubation in
Awake Ankylosing Spondylitis
Thida Uakritdathikarn MD et al
case report
Just proximal to cuff is better choice with 6-6.9 cm from tip is ideal place to bent the tube
Trauma to the upper airway after lighted stylet intubation is generally of a minor nature and includes bleeding, sore throat, hoarseness, and dysphagia
Rarely lost bulb in smaller airway
arytenoid cartilage dislocation
Hoarseness after any tracheal intubation may be a sign of arytenoid subluxation and should be referred
Rare and Minor
Minor trauma
Lost Bulb
Arytenoid dislocation
Thank you for your attention
Lighted Stylet Tracheal Intubation: A Review
Lionel Davis
An Algorithm for Difficult Airway Management, Modified for Modern Optical Devices (Airtraq Laryngoscope; LMA CTrach™)
Table 3. Outcome of Airway Management of All Anesthetized Participants (n 12,221) and of Patients with Airway

Anesthetized patients (n 12,221)
Failure using Macintosh laryngoscope 236 (2.0)

GEB use with Macintosh laryngoscope (n 236)
GEB success 207 (84)
A 2-Year Prospective Validation in Patients for Elective
Abdominal, Gynecologic, and Thyroid Surgery
Roland Amathieu, M.D. Anesthesiology, V 114 • No 1

Failure using Macintosh laryngoscope + GEB 29 (0.2 %)
narrow diameter tracheal tube introducer with an outer diameter of 5 mm. originally produced by portex called eshmann stylet.
we share common academic interest and partenership in practice and hospital
Indications: Nasal FOI
Lignocaine gel,
local spray,
Topical application
Drugs: 2-4% Lignocaine with epinephrine
Anesthesia of the Nasal Mucosa and Nasopharynx

The patient is placed supine
Line is drawn between the angle of the mandible and the mastoid process.
Using deep pressure, the styloid process is palpated just posterior to the angle of the jaw along this line
A short, small-gauge needle is seated against the styloid process.
The needle is then withdrawn slightly and directed posteriorly off the styloid process. As soon as bony contact is lost, 5–7 ml of local anesthetic solution are injected after careful aspiration for blood.
Glossopharyngeal block-
Non invasive method
Gel applied over tongue spatula-
pt swallow the gel- 15 min
Gargle -4 ml 4% xylocaine
Nebulization of 4 ml 4% aqueous solution
10% xylocaine spray

Invasive method-
Glossopharyngeal Block
Intra oral approach
Peristyloid approach

Local Anaesthesia for Fiberoptic Intubation : A Comparison of Three Techniques
Lt Col N Sethi ,

Gag reflex
Glottic closure reflex
Cough reflex

What are the
difficulties in establishing
awake airway
When do we need
awake airway control
Anesthesia of the Nasal Mucosa and Nasopharynx
Technique: wide cotton pledgets soaked in the local solution (lignocaine) are applied over the nasal mucosa by inserting cotton pledgets into both nares
2-5 mins
They should be done bilaterally provide posterior pharyngeal anesthesia, caudad to this level.
Locate cricothyroid membrane. Cricothyroid membrane is spongy gibromuscular band between thyoid and cricoid cartilages.

Skin preparation

Small skin wheel of LA at site of punctre

Syringe with 22g iv cath advanced while being aspirated.

Whan free apiration of air is present , needle is removed. And 4-5 ml of 2% lignocaine is sprayed. This invariably evolkes coughing

With coughing the LA is disperesed in the entire trachea and larynx.
Transcricoid injection
Provides sensory innervation to the vocal folds and the trachea and

Motor innervation to all the laryngeal muscle except cricothyroid muscle

Sensory blockage provideds comfort and prevent coughing while the endotracheal tube is being passed between the vocal cords
Recurrent laryngeal nerve block
the mouth is opened and the tongue is anesthetized with topical anesthetic
A 3 1/3 -in., 22-gaugue needle is used to place 5 ml of local anesthetic solution submucosally at the caudal aspect of the posterior tonsillar pillar (palatopharyngeal fold)
Glossopharyngeal block-
Non invasive methods
Topical methods-
Local application
Left for 5–15 minutes on the region of mucosa that requires anesthesia.

Individual nerve blocking-
Glossopharyngeal block
Superior laryngeal block
Recurrent laryngeal N

Various methods of
anesthetizing airway
A comparative study of
dexmedetomidine with midazolam and midazolam alone
for sedation during elective awake fiberoptic intubation
Sergio D. Bergese MD et J Clin Anesth. 2010 Feb

Dexmedetomidine versus remifentanyl
sedation during awake fiberoptic nasotracheal intubation - a double blinded randomized controlled trial, Hu R et al . J Anesth 2010 oct

Anti cholinergics
improve fibreoptic intubating conditions during general anaesthesia.
Brookman CA, Teh HP, Morrison LM.
Explanation- key factor

Most patients require some degree of sedation and analgesia.


Nasal route preparation
Look for patent nostril
Topical nasal vasoconstrictors
Preparation for airway anesthesia
Reflexes of airway
Superior laryngeal N Block
Simple technique

Nebulizer or Atomizer, 2-4 % ligoncaine

Inhalation of Aerosolized (Atomized) Local Anesthetic
Non Invasive Method (less common)
Patient is asked to open the mouth widely, and the tongue is grasped using a guaze pad or tongue blade.
A right angle forcep is covered with anesthetic-soaked guaze and is slid over the lateral tongue and down into the pyriform sinuses bilaterally.
Cotton swabs are held in place for 5 minutes.
Part of glottic closure reflex
Sensory innervation to larynx above Vocal cord, posterior part of epiglttis,
motor innervation to cricothroid muscle
Superior laryngeal nerve blockage
Viscous lidocaine 2-4 ml may also be used as a
(swish and swallow) for approx. 30 sec.

Non invasive methods
Topical methods-
Local application
Planning the predicted difficult
airway management
If the intubation with standard laryngoscopy
is deemed impossible or extremely
difficult, the widely acceptedThis choice is thought to be the

safest because it maintains spontaneous ventilation,
protective reflexes, oxygenation, and,
moreover, allows even an inexperienced
operator to identify the anatomical landmark
and to proceed with the fiberscope, because
the muscular tone is maintained

Anticipated difficult airway management

It is paramount to keep the patient conscious and breathing spontaneously
until the airway is secured using a pharyngeal or tracheal instrument specifically designed for airway maintenance (Fig 3).
In an uncooperative patient, at least spontaneous breathing should be maintained.
Techniques for Difficult Intubation

Alternative laryngoscope blades

Intubating stylet or tube changer
Laryngeal mask airway as an
intubating conduit
Light wand
first choice technique
is awake fibreoptic intubation with
topical anaesthesia (with or without light
Fibre optic intubation or placement of a
laryngeal mask with the patient awake
and/or under mild sedation and
local anaesthesia are associated with
a high success rate and low risk.
Awake intubation
Blind intubation (oral ornasal)
Fiberoptic intubation
greater and lesser palatine
and ethmoidal nervce
Larynx and Trachea- Vagus nerve
Superior laryngeal n.
Recurrent laryngeal n.
Patient Position: Patient is most comfortable when head of bed is elevated approximately 30˚.
Topical nasal anaesthesia
which one is better?
 lignocaine gel is a simple technique, effective and less irritating as compared to lignocaine spray for topical nasal anaesthesia.M, Singapore Med J. 1993 
palpate the hyoid bone cornua on both side
displace bone towards side to be injected
insert the needle and walk of the cornu
puncture the thyrohyoid membrane
aspirate and inject

Anterior 2/3 of tongue do not take part in any reflex action - dose not require blockage
Rest area- posterior 1/3 of tongue, oropharynx , pharyngeal surface of epiglottis supplied by glossopharyngeal nerve
The nasal cavity is entirely innervated by fibers carried by branches of the
trigeminal nerve.
Ant. Parts of the nasal cavity and the septum – ant. ethmoidal nerve ( a br. of the ophthalmic nerve)
The remaining parts of the nasal cavity and the septum – br. of the maxillary nerve, including lateral posterior superior, inferior posterior, and nasopalatine nerves.
These branches are relayed through the
pterygopalatine ganglion
which is situated in the pterygoid fossa lateral to the sphenopalatine foramen at the level of the crest of the superior turbinate
Mainly innervated by
Visceral fibers – posterior third of the tongue, the fauces and tonsils, epiglottis-pharyngeal or anterior surface
Anterior 2/3 of tongue innervated by Trigeminal nerve- do not take part in airway reflexes
The superior laryngeal nerve dividing into internal and external branch.
a. internal br. – through a foramen in the thyrohyoid membrane and provides visceral sensory and secretomotor innervation to the larynx above the true cords.
b. external br. – supplies with motor fibers of the cricothyroid muscle.
Recurrent laryngeal nerve
providing both structures with fibers for visceral sensation, motor and secretomotor innervation, and sympathetic branches.
it enters the larynx by passing the lower border of the inferior constrictor m. of pharynx.
it supplies all muscle of the larynx except cricothyroid and conveys visceral sensation to the cords and infraglottic regions.
for your
drug , and its dosage
- Sytemic absorption caused
CNS & Cardiac Toxicity

- Methhemoglobinemia
Rarely reported with the lignocaine
but common with
the other commonly used agent in
US benzocaine.
A Guidance on the Use of Topical Anesthetics for Naso/Oropharyngeal and Laryngotracheal Procedures
How much safe & convenient it is?
Awake Fibreoptic Intubation Course
Date: Wednesday
Time: 08.30 – 14.00
Meet in Anaesthetic Trainees Coffee Room
– 3rd Floor Maples Link Corridor
By Theatres
Venue: 3rd Floor Podium
Course Organisers
Dr Simon ClarkeConsultant Anaesthetist UCH
Dr Damon Kamming Consultant Anaesthetist UCH
Dr Raman Verma Consultant Anaesthetist UCH
Kindly supported by Storz
Airway Endoscopy Under Local Anaesthetic
Before volunteering for an awake fibreoptic endoscopy you will need to understand what is involved, the risks of the procedure and exactly how you can expect to feel during and afterwards.

Method The procedure takes place in an operating theatre with full resuscitation facilities available.
Topical co-phenylcaine spray is applied to both nostrils.. Oxygen will be administered, followed by the topical application of lidocaine (fine spray throughout the airway via atomiser ).

When satisfactory anaesthesia has been achieved, course members will perform airway endoscopy under direct supervision with further application of lignocaine via the fibreoptic scope.


Intra-vascular injection

Local hematoma

Subcutaneous emphysema

Aspiration ???
Procedural complication
Drug over dose
studied on 500 patient- 2.4% complication of glossopharyngeal block- intravascular injection, headache etc.
No complication with SLN
studied on 500 patient- 2.4% complication of glossopharyngeal block- intravascular injection, headache etc. No complication with SLN
Spraying or swishing of local anesthetic directly onto the mucosa of the mouth, pharynx, tongue, and/or nose.
Local anesthetics
2-4% lignocaine solutions, gel most preferred drug
American College of Chest Physicians consensus
statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients Wahidi mm et al  Chest.  2011
 Lidocaine is the preferred topical anesthetic
for bronchoscopy, given its short half life and wide margin of safety

Spray-as-you-go airway topical anesthesia in patients with a difficult airway: a randomized, double-blind comparison of 2% and 4% lidocaine. Xue FSAnesth Analg. 2009 FebCONCLUSIONS:
Both 2% and 4% lidocaine
administered topically by a spray-as-you-go technique can
provide clinically acceptable intubating conditions,
compared with 4% lidocaine, however, 2% lidocaine requires a smaller dosage and results in lower plasma concentrations.

Plasma concentration of lidocaine during bronchoscopy].
an average total dose superior to 400 mg appears to be safe
in patients undergoing FOB. Sucena M , Rev Port Pneumol. 2004

mean plasma lidocaine concentration at initiation of intubation in the topical anesthesia group was half that of nerve block group (2.16 versus 4.23 micrograms/ml; p < 0.0001)
A comparison of anesthetic techniques for awake intubation in neurosurgical patients.
american bronchoscopy association and veteran hosp recommendation - systematically reviewed the literature- recommendations are- lignocaine the drug of choice as against- benzocaine, tetracaine etc, fortunately that is the only drug available here
2-4% again evidence tilt in favour of 2 % as both almost produce same effect than why to use larger dose.
there is generally two way- topical method where you try to anesthetize the mucosa of area for the instrumentation- you donot aim for specific nerve block or area- many are one fit all methods
or you block specific nerve or area
all evidence suggest that one single method is never sufficient and you need more or less combination you are comfortable

Most of them produce effective method
Noninvasive becoming more popular methods
as i have already said generilzed method were local anesthetics comes in direct contact of the mucosa-
you can use 4 % viscous for gargling if your patient can do it or spray convinient for you little discomfort for the patient but reasonably block the area well- each spray gives 10 mg /ml - you know how much dose you have given
or use working channel of FOB to instilled LA before you proceed at every step- this method is gaining popularity
this method of putting swabs soaked in la does produce dense blockage of area,
considered method of choice by ENT surgeon for blocking the nose
or you put them in visinity of nerve like SLN in pyriform fossa to produce block
when you learn about this metho for the first time - you feel oh this fantastic, for oral , nasal, larynx - all area can be anesthetized by single method- convienint, you dont need to remember this lecture - you put mask and forget about doing anything else- well it has problem of patchy effect and you need to supplement this with other methods
Now we will look in to specific area blockage rather than a generilized method-
oral cavity and oropharynx-
just read
for oral cavity what you need to block is glossopharyngeal block - non invasive methods are popular in this case- as they produce effective local anesthesia and invasive methods are more riskier compared to other blockage - because nerve in vicinty of highly vascular area- chance of complication as well as- higher blood concentration of la becuase of faster absorption is there.

spray is technique what we practice routinely
Require wide mouth opening-semireclining posture, cooperative patient, you still need to give local anesthesia in area of injection- slightly difficult block and tony reported 2.4 % chances of complication- hematoma- intravascular injection, convulsion , headache etc
not very popular
we are not practicing routinely- and video is not very good - its ameturis attemp of video shooting by another doctor-
it is difficult to take video while you are giving injection
if you donot have wide mouth opening and some how patient is not cooperative or not opening the mouth at all- than you can block glossopharyngeal block from the peristyloid approach -
speak the step
again you are in vicinity of large blood vessels
read the anatomy part
when done properly allow easy entry of FOB in to larynx
easy to perform and high success rate.

If there is previous surgery or neck scarring and you cannot locate hyoid or thyroid than you can use this noninvasive method ,

locating hyoid is one approach, you can also palapte thyroid cartilage and go up to locate the thyrohyoid membrane - to block this nerve
Local anesthetic administration for awake direct laryngoscopy. Are glossopharyngeal nerve blocks superior? Sitzman bt anesthesilogy 1997
Glossopharyngeal nerve blocks do not provide a superior route
of local anesthetic administration for awake direct laryngoscopy. Two minutes of 2% viscous lidocaine S&G followed by 10% lidocaine spray was the anesthetic route preferred by participants and laryngoscopists.

Indian J Anaesth. 2011
Transcricoid puncture for diagnostic bronchoscopies without sedation was associated with no complication and discomfort and required lesser dose of local anaesthetic with more stable vitals and good conditions for bronchoscopists.
Fibreoptic bronchoscopy without sedation: Is transcricoid injection better than the “spray as you go” technique? Alka Chandra et al
The aim of the study was to compare three different methods of anaesthetizing the airway. -
transcricoid injection, spray as you go, Nebulization
Episodes of coughing, choking, stridor, extra / total local anaesthetic used and intubation times were recorded. . Results: Spray as you go patients showed better VAS scores with shorter intubation times and had a lower incidence of coughing and choking. The endoscopists’ VAS scores also showed a preference forSpray as you go.
Conclusion: In conclusion the ‘spray as you go’ technique was safe, provided effective local anaesthesia and was preferred by both patients and endoscopists.
Topical nasal anaesthesia for fibreoptic bronchoscopy: lignocaine spray or gel? Zainudin B
Topical anaesthesia of the nasal mucosa for fibreoptic airway endoscopy.Randell T Br J Anaesth. 1992
Application of lignocaine spray was rated as the most unpleasant, Gel or EMLA, but not the local anaesthetic applied with swabs, obscured vision. When slight obscurity of vision is not a problem, local anaesthetic gel is recommended for anaesthesia of the nasal mucosa. If obscurity is a problem then swabs are best.
Ultrasound in
Airway Block
Currently, the role of ultrasound (US) in anaesthesia-related airway assessment and procedural interventions is encouraging, though it is still ill defined
A method for ultrasonographic visualization and injection of the superior laryngeal nerve: volunteer study and cadaver simulation.Kaur B, etal Anesth Analg. 2012
ultrasound-guided superior laryngeal nerve block in humans may be feasible
Forty patients were randomized to either topical anesthesia or nerve block groups.J Neurosurg Anesthesiol. 1995 Reasoner DK etal
Time required for successful intubation and quality of intubation were not different between groups. Physiologic values for the two groups were similar. There was no difference in patient perception of discomfort during the procedure
Combined nebulization and spray-as-you-go topical local anaesthesia of the airway K. A. Williams et al BJA 95
This method of airway anaesthesia was acceptable to this small group of unsedated subjects. It produced good conditions for fibreoptic intubation. A maximum calculated lidocaine dose of 9 mg kg1 did not produce toxic plasma concentrations of lidocaine
The Efficacy and Safety of EMLA® Cream for Awake Fiberoptic Endotracheal Intubation Ghassem E et al. Anesth Analg 2000
We conclude that EC provided satisfactory topical anesthesia allowing for successful oral fiberoptic intubation in all patients and should be considered a safe alternative for anesthetizing the airway of patients requiring awake oral fiberoptic intubation.
Local nerve block-Anesthesia for peroral endoscopy Tom R etal, glossopharyngeal block and SLN,
Veteran hospital recommendation for topical anesthesia of airway, sytematic review of literature
Local nerve block-Anesthesia for peroral endoscopy , Tom R etal, glossopharyngeal block and SLN,
Which one is better???

We describe the successful performance of ultrasound-guided bilateral superior laryngeal nerveblock to facilitate awake fibreoptic intubation in a patient presenting for emergency surgery on the cervical spine.
Ultrasound-assisted translaryngeal block for awake fibreoptic intubation. De Oliveira GS Jr, Can J Anaesth. 2011 Jul
Ultrasound-guided bilateral superior laryngeal nerve block to aid awake endotracheal intubation in a patient with cervical spine disease for emergencys surgery. Manikandan S, Neema PK, Rathod RC.
Anaesth Intensive Care.
Each delegate will perform airway anaesthesia and the endoscopy procedure on the other 2 delegates in turn.
No method is better than other
choose what is available and you are comfortable
Non Invasive method
still first choice for the oropharyngeal anaesthesia
Topical or Non Invasive Technique- to block the sensory afferent for larynx and trachea both
Spray as you go
Cotton swabs in Pyriform fossa to Block the SLN
To prolong the duration of nerve blocks, reduce absorption
Causes mucosal vasoconstriction, which improves visualization during the procedure and helps limit bleeding.
Local anesthetic-soaked cotton pledgets or swabs. These are soaked in either viscous or aqueous solutions of local anesthetic and then left for 5–15 minutes on the region of mucosa that requires anesthesia. The cotton acts as a reservoir for the anesthetic agent, producing a dense block. This technique is especially effective in the nasal passages applicationof highly concentrated local anesthetic-soaked cotton pledget reservoirs can be exploited to achieve highly specific nerve blocks
Local anesthetic-soaked cotton pledgets or swabs.
Peri styloid approach

Intra oral approach
glossopharyngeal nerve
Sympathetic fibers – derived form the carotid plexus and the cervical sympathetic trunk
Efferent motor fibers – innervate the stylopharyngeus muscle and join the pharyngeal plexus.
Cotton gauge, pledgets
VINS- Vadodara Institute of Neurological sciences
Director and consultant Anaesthesiologist

Glossopharyngeal Block
Peristyloid approach
Superior Laryngeal Block
Invasive Non
Non invasive
Transcricoid injection
I will not speak about restricted mouth opening or no neck movement etc.
important point is whenever you anticipate that ventilation or intubation is going to be difficult keeping the patient awake while establishing the airway is gold standard, endorsed by all most all algorithms

Vagus (X)
Glottic closure
laryngeal N
Vagus (X)
Recurrent Laryngeal N
Vagus (X)
Laryngeal N
Vagus (X)
Vagus (X)
Explanation- key factor Nearly every patient experiences some degree of anxiety. Most patients require some degree of sedation and analgesia. Fentanyl, Midazolam, Dexmedetomidine Antisialogogues Atropine or glycopyrolateNasal route preparationLook for patent nostrilTopical nasal vasoconstrictorsNeosynephrine XylometazolineOxymetazoline
10-20 mL syringe can be filled with lignocaine 2–4% and sprayed over mucosa via a small-bore single or multi perforated catheter or the working channel of the fiber optic bronchoscope as you progress.

Non invasive methods
Topical methods
spray as you go
Simple technique

Local anesthetic (
-4% lignocaine) is added to a
standard nebulizer
with a mouthpiece or face mask attached - for 15-30 min
Focused aerosolized local anesthetic from an
is ideal for nasal intubation

Major advantage
lack of discomfort.
very little working knowledge of the anatomy of the region is required

Disadvantage –
density of the anesthesia achieved throughout the airway is highly variable
Blood concentration may be high as large dose of drug reach lower airway, which has large surface area
Anesthesia of the Larynx and Trachea
Invasive techniques-
Superior Laryngeal nerve block &
Transtrcheal ( transcricoid ) injection
Non invasive methods
Topical methods
Local application –
Local gel,
Solution with cotton pledges
Local spray
- sytemic absorption caused
CNS & Cardiac Toxicity
visual disturbance
muscle twitching
cardiac collapse
- Methhemoglobinemia
Rarely reported with the lignocaine
but common with
the other commonly used agent in
US benzocaine.

Nasal blockage-
epistaxis or trauma
Glossopharyngeal block-
trauma to major vessels
intravascular injection
Superior laryngeal nerve-
local hematoma
Recurrent laryngeal nerve-
risk of coughing
vascular injury
structural injury
subcutaneous emphysema
Aspiration ???
Nerve Blocks
block the cough refelx
Block the glottic closure reflex
Bilateral Block
Better Method ??
Dr Amit Shah
Dr Apeksh Patwa

VINS- Vadodara Institute of Neurological sciences

Director and consultant Anaesthesiologist VINS
Muniseva Ashram , Cancer H GORAJ

Primary airway devices
Airway blocks

all patients assesed for the difficult airway
over 2 years of period
No difficulty expected
Direct laryngoscopy
If failed
59 pt
all succesful
expected difficulty
206 pt
only 2 pt requiered FOI
Optical-audio feedback systems use the fine frequency
discrimination of the human ear to direct the tube past
the glottis This technique relies on the principle
that human hearing is more sensitive than visual detection
and that therefore converting light intensity to
an audio signal will enhance the changes in a visual
Technical Report
The use of an endotracheal ventilation catheter in the management of difficult extubations Richard M. Cooper
can j Anaesth 1996/43:1/pp90-3
Compared with remifentanil, dexmedetomidine offered better endoscopy scores, lower recall of intubation, and
greater patient satisfaction, with minor hemodynamic side effects.
Anatomy we should know for Airway anesthesia
What route ?
Airway anaesthesia is simple , very effective technique and must know for all anaesthesiologist.
Topical anaesthesia, either
local anaesthetic gel or swabs
Local application- 10% Lignocaine spray
Invasive block- SLN, RLN or

spray as you go
Dr Amit Shah
Dr Apeksh Patwa
What device, method ?
Non invasive / Topical generalized techniques-
Spray as you go
Nebulization of local anesthetics
Use of atomizer for the local anesthetics
Local application – gel, solution with cotton pledges
Vasoconstrictors such as epinephrine (1:200, 000) or phenylephrine (0. 05%) can be added to the solution to
Safe dose considered upto 400 mg,
2 % or 4%???-
Nebulization / atomization of local anesthetics
Spray as you go
A pressurized solution local anesthetics in a small bottle , delivers a spray via a long
nozzle that is pointed in the desired direction
Each spray delivers 10 milligrams of lignocaine
Can be used for Nerve block if Nerve is below the mucosal surface- SLN
Especially effective in the
nasal passages
The cotton acts as a reservoir for the anesthetic agent, producing a
dense block.
Disadvantage –
density of the anesthesia achieved throughout the airway is highly variable
Blood concentration may be high as large dose of drug reach lower airway, which has large surface area
Major advantage
Lack of discomfort.
very little working knowledge of the anatomy of the region is required
Local gel or cotton pledgets or atomizer all works equally well can be used according to your comfort level
Non Invasive method
still first choice for the oropharyngeal anaesthesia
We use invasive technique when ever feasible or spray as you go if block cannot be given.
Proper preparation , adequate sedation and titrated drug usage for various techniques is must for successful airway anaesthesia
More than one techniques, and combination of invasive and non invasive techniques usually require to achieve complete anaesthesia.
Applied anatomy
When do we need awake airway control ?
Anticipated difficult airway
Italian guidelines
ASA guidelines
German Guidelins
It is paramount to keep the patient conscious and breathing spontaneously
until the airway is secured
To secure airway while patient is conscious it is necessary to give airway anesthesia
We need to apply more than one technique to give complete anesthesia
Kailash cancer hospital , Muni seva ashram , Goraj
Chief Consultant Anaesthesiologist
When do we need awake airway control ?
Italian guidelines
ASA guidelines
German Guidelins
It is paramount to keep the patient conscious and breathing spontaneously
until the airway is secured
To secure airway while patient is conscious it is necessary to give airway anesthesia
When you are unsure of ventilation of patient
Opthalmic division -Trigeminal N
Maxillary division
Pterygopalatine ganglion
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