Letters to the Editor
To the Editor:
As fiberoptic bronchoscopy becomes part of the armamentarium of all anesthesiologists for securing the airway, multiple techniques have been described and utilized. These techniques involve antisialogog treatment; nebulization of local anesthetic solutions; topicalization of the airway with sprays, pledgets, and cotton swabs, as well as invasive peripheral nerve blocks of the nasal and oral pharynx. Most of these require significant time to prepare and administer and may be quite uncomfortable and anxiety-provoking for the patient. We all know how necessary thorough anesthesia of the airway is for instrumentation and intubation in the awake patient. The following describes a simple and timely method of anesthetizing the oropharynx for oral fiberoptic intubation.
It is important to administer an antisialogog, i.e. glycopyrrolate, before beginning for the local anesthetic to be effectively delivered to the oropharyngeal mucosa. To anesthetize the tongue and oral cavity, 10% lidocaine spray is used with the tongue protruded, approximately two to three sprays (each spray contains 10 mg of lidocaine). A large hollow oral airway with the distal third coated with 2% lidocaine jelly is placed a third of the way into the patient's mouth. This is repeated twice more, each time with approximately 2 mL of jelly applied to the end and moved further into the mouth. With each application, the patient is asked to open wide with the tongue out and to take the airway in as far as is tolerable. This elicits patient cooperation and gives them a measure of control in their care and your efforts. With the last one-third application and the airway fully in the mouth, the patient is instructed to inhale and exhale through it as if the airway were a straw. As the patient inhales, two to three puffs of 10% Lidocaine are sprayed into the hollow center of the airway and are drawn to the glottis. This is then replaced with an intubating oral airway, e.g. Ovassapian, with the endotracheal tube engaged, and bronchoscopy proceeds as routine. Often, the vocal cords are anesthetized by the above measures and no further topicalization is necessary; however, a small amount (2 mL of 2% lidocaine) may be sprayed through the injection port of the bronchoscope just before advancing past the cords. The full time for this process is approximately 8 mins. Patients tolerate this procedure well even without sedation; however, sedation (most frequently with midazolam or midazolam/fentanyl combinations) is recommended for patient comfort and anxiolysis.
This method is especially useful in patients who are needle shy, whose oropharyngeal anatomy is difficult to access for peripheral nerve blocks, and those with surgical or radiation altered anatomy. This technique may be used, in addition to the operative indication, for difficult airway procurement on the ward, in the intensive care unit, and timely and comfortable endoscopy and bronchoscopy suite experiences.
Maria E. Fagan Shier, MD
Department of Anesthesiology; Long Beach Veterans Affairs Medical Center and University of California at Irvine; Orange, CA 92668