Video 1: Awake fibreoptic intubation
Authors: Drs Tim Strang and James Palmer
Running Time: 20 min (Approx)
Available from: Dr T. Strang, Consultant Anaesthetist, Manchester Royal Infirmary, Manchester M13 9WL, UK
Price: £12.50 (UK), postage extra overseas
This video was shown in pre-production form at the Difficult Airway Meeting at Guy's Hospital in December 1995 and was well received. It is entitled 'awake fibreoptic intubation' but covers in considerable detail the local anaesthetic blocks required to perform an awake intubation by any means. Dr Strang convinced his Senior Registrar that it would be in his best interest to be filmed undergoing awake intubation and James Palmer agreed.
The video covers, sequentially and sensibly, aspects of the techniques involved. These include preparation of the patient; the nerve supply of the respiratory tract; techniques for blocking the nasal mucosa, the lingual branch of the glossopharyngeal nerve, the superior laryngeal nerve and translaryngeal injection of local anaesthetic; fibreoptic intubation via the nose and mouth.
What are the good aspects of the video? Certainly that it exists at all and is very reasonably priced. Both aspects are a great credit to the authors. The blocks themselves are well presented and demonstrated on a human being, rather than a model, so that not only can the block be seen but also the patient response to the injection of local anaesthetic. For example, the vigorous swabbing of the pharynx without patient response demonstrates clearly that glossopharyngeal nerve block does abolish the gag reflex and the coughing induced by cricothyroid injection is present but short lived. The unhurried, trouble-free awake fibreoptic intubation that is possible with very good quality local analgesia is well demonstrated. Confirmation of correct tube placement by capnography is emphasized.
What could be improved? The video is keenly priced and this represents the fact that the video is produced in-house and is not of top-quality professional standard in video image or sound quality. However, it is quite watchable. Quite a lot of spoken information is given with regard to local anaesthetic concentration/volumes required and this could usefully be summarized with text slides and text summaries of important points, including maximum recommended doses. Instillation of local anaesthetic down the suction channel is not covered. The demonstration of blocks in a subject with normal landmarks and mouth opening does not give a good idea of which blocks are essential, advisable or possible in clinical situations. The length of the video mitigates against being able to cover both local anesthetic blocks and techniques of fibreoptic intubation in detail, and some basic fibreoptic techniques are missed out.
Video 2: Awake fibreoptic intubation
Author: Dr Ian Calder
Running time: 25 min (Approx)
Available from: Dr I. Calder, Consultant Anaesthetist, Royal Free Hospital, Pond Street, London NW3 2QG, UK
Price: £10 + postage
This video reflects the considerable experience gained by the author in awake intubation at the Royal Free and National Hospital for Neurology and Neurosurgery. It covers fibreoptic intubation utilizing only the spray-as-you go administration of local anaesthetic through the suction channel. The video progresses through patient preparation and premedication to the technique itself. Technique and tips are shown on mannikins and real patients.
Although the video is produced in-house, the quality of image and sound is very good despite the occasional hesitancy of speech. It is narrated by Dr Calder who frequently speaks to camera. His clinical experience allows considerable depth of presentation. Text slides and text overlying screen images increase the accessibility and retention of spoken information. Useful tips abound. The anatomy of the nose and nasopharynx are detailed with captioned freeze-frames. Fibreoptic technique and the administration of local anaesthetic are covered in detail. The highlight of the video is the intubation of a difficult patient in earnest, demonstrating the problems that may arise in actual patients and the inherent safety of an awake technique.
What of the deficiencies? The video is a fairly single-minded in the promotion of the spray-as-you-go technique and this represents Dr Calder's practice. No other local block is described. The approach is actually relatively time consuming and the spraying of local anaesthetic on to areas which are not numb produces a fair amount of patient response whilst the endoscopy is undertaken. Inexperienced endoscopists find it difficult to repeatedly find the larynx only to spray it and then lose the view because of gagging, swallowing or coughing. Perhaps a more balanced view is that local anaesthetic blocks prior to endoscopy are preferable in some patients.
Overview of both videos
It can be seen that these two awake intubation videos reviewed here complement each other extremely well. The first video concentrates on local blocks with some fibreoptic technique; the second details spray-as-you-go, concentrating on fibreoptic technique. Clearly, these two videos represents the authors' views on awake techniques. Trainees and consultants at the reviewers' hospital have found these videos extremely useful. They are ideal for inclusion in a Calman style airway module and contain useful, practical information that will assist anyone undertaking or contemplating awake intubation. They are recommended for all hospital departments and anyone with a particular interest in airway management.
Both videos together cost only £25. It is difficult to imagine teaching difficult airway management without access to these two videos. Buy them both.
A. C. PEARCE; A. P. ADAMS