Awake Endotracheal Intubation

By Adem Lewis / in , , , , , , , , , , , , , , , , , , , , , , , , , , , , , /

(music) (train noises) (music)>>I would like this video
to throw some light on awake oral
endotracheal intubation. There are many situations
where an awake intubation is a useful technique, or
perhaps even a standard of care. For example, a patient
with angioedema affecting the
upper airway may benefit from an
intubation performed awake. Administering a syringe
of Propofol or Etomidate will cause unconsciousness and
may aggravate airway obstruction and certainly leave the
airway unprotected. Administering muscle relaxant
will stop spontaneous breathing. And, as a practicing
anesthesiologist, I always consider keeping
someone awake and breathing as a priority and
a possible Plan A. (music) At the cricothyroid membrane, now
everyone feel theirs. It’s at the top of your neck–
the top bump– is the thyroid
cartilage. That’s the notch. And then, when you come
down a little bit, you’re going to– before you
get to the cricoid cartilage, you’re going to get to the
cricothyroid membrane. Nothing is there. I do it
every year. (music)>>So, alcohol swab. Are you ready?
>>Mmm-hmm.>>Needle goes in. We just sit there
for a minute. And– well,
two seconds. He’ll withdraw
bubbles slowly.>>Three CC’s… slowly….>>And then, just get the
3 CCs in and pull out. (coughing)>>Perfect.
(all laughing) (coughing) Yeah! Because you want to spread
it around the trachea. (all laughing) The next thing I’m gonna do is
I have 5 more CCs of lidocaine. And this will go
on the fiberscope. And this way, we can spray
structures as we see them. Mmm-hmm. Mmm-hmm! (music) Okay, so we saw the cords
and sprayed them. And we’ll get
started again. (music) Mmm-hmm. (humming playfully)
(scattered chuckling) (high-pitched humming) (music) (applause) (music) (applause) The point behind this, is
that awake intubations can be done right in
front of your eyes. There was nothing
magical today. In general, this is
pretty straightforward. Basic technique. (music)

100 thoughts on “Awake Endotracheal Intubation

  1. Unbelieveable. Most institutions will not allow this. It is very educational thought. This is great. Keep up the good work.

  2. Can patients get methemoglobinemia from all the local anesthetic in this procedure? I have had patients that got it from benzocaine spray before coming to the unit but I don't think I have ever seen it from lidocaine.

  3. Besides the transtracheal injection and spraying the cords did you do any other topicalization? No 5% lido to base of tongue, atomized lidocaine, or plegets to the piriform fossa?

  4. Yes, during the lecture I gargled with 2% viscous. This video represents excerpts from an hour lecture on securing the airway for ATLS.

  5. Yes, I agree Minu, Transtracheal was only performed to show the technique. It is not needed, as one can 'jet" lidocaine thru the fiberscope especially if one flushes the lido through with oxygen at 4 0r 5 L/min.

  6. Well that's nice and dandy, but how about working without ibre optic, which would be far more interesting for me (Paramedic)?

  7. You are right Satananass; intubating without tools takes even more skill sometimes! As you know, field intubation is frequently performed nasally in a spontaneous breathing patient. Good technique is to observe the exact centimeter mark (at the naris) when the breath sounds (or/and ETCO2 if you have hooked it up) disappear. This tells us that the ETT tip has just bypassed the laryngeal inlet, and you need to back up 1 – 2 cm and change angle of approach.

  8. Hi Michael, what sort of connection would you use to jet the lignocaine with oxygen through the fiberscope channel
    is a three way tap good enough?

  9. Dr. Zamudio, a three way tap is good enough – provided it fits! Some brands have a luer connnector that gets in the way, and you may need to snip it off with a strong scissor. You can connect oxygen tubing to the fibrescope, and when you flush oxygen, the syringe plunger can be jettisoned if the tap is not turned correctly (closed to scope). You need to be quick to get a good spray. Give 2cc, then close tap, then jet the oxygen.

  10. Many people says: Orotracheal intubation means general anesthesia. This is a wonderful proof than one thing has nothing to do with the other. 
    Congratulations Dr. Balin!

  11. That's a really cool demonstration of awake intubation….. It's actually a scary topic for a lot of anesthesiologists and patients alike…… Little bit of patience, correct technique and time and of course…. Dr.Bailin….. And voila…. Perfect recipe for a perfect intubation

  12. Just a layperson here but if he gave himself an infection, then perhaps next time he would wear gloves. I once saw a guy break ice, wood and bricks with his head and another eat glass and they all say it is simple, cool etc. I guess it depends which side of the rubber hose you are on. Still, very cool video that I will pass along. I likes the music videos better 🙂

  13. Hi Dr Bailin. I am R1 of anesthesiology in " Hospital Das Clinicas , Faculdade de Medicina da Universidad de Sao Paulo" , Brazil. Are you interested in teaching a Conference of difficult airway management?

  14. Wow. Great demonstration.
    At first congratulations for demonstrating on self which requires courage, confidence, skill and knowledge .
    Perhaps this is best awake intubation video.
    I am presenting a case report in World Congress and I would like to mention your video as reference if you permit.
    Ravindra, India.

  15. if all doctors have been like you then all students will become professors in just few years
    I wish i had a brave doctor like you
    well done.

  16. brave doctor… i had two endoscopies…first one was total panic…next was ok and a game of nerves…much like sword swallowing by miracle mongers…practice… ur trachea…bronchi look nice….non smoker han…

  17. OMG, I would LOVE to have him as an Instructor! He is awesome!!!!!! His passion for what he does is just endless! Keep doing what you are doing, wish there were more like you!

  18. Never going to use it or have it practiced. Good luck. If someone has an airway that delicate from what he said they're getting sedated and a cric. Noone is going to wait for an awake intubation, nor will it help for any procedure you plan to accomplish in an emergency. This guy is a cowboy.

  19. I don't know. I would be "Please give me Propofol or Versed and Fentanyl". I am a big chicken when it comes to medical procedures.

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