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Steps for a successful Awake Tracheal Intubation



Join esteemed anesthesiologist from Brazil, Dr. Ricardo Zanzi, as he demystifies the complexities of awake tracheal intubation in a highly instructive on-demand teaching session. Understand the importance of making informative judgments and choosing the correct methodology for each patient while conveying its merits to the patients themselves. Delve into crucial concepts through comprehensive comparison of direct laryngoscopy with video laryngoscopy in terms of safety, success rate, and hypoxia occurrence. Evaluate how video endoscopy stacks up in situations of awake tracheal intubation. Benefit from insightful statistical analyses, and learn the five crucial steps for executing a successful intubation, beginning with the often overlooked first step of patient consent and explanation. This information-packed session is a must-attend for all medical professionals aiming to enhance their tracheal intubation proficiency.
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Awake tracheal intubation is a critical skill in emergency and critical care settings, Ricardo is going to take you through a step by step of this in our event

Joining us today is Ricardo Zanlorenzi, Consultant, Anaesthetics and intensive care medicine, Brazil

None of the planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Dr. Zanlorenzi, faculty for this educational event, has no relevant financial relationship(s) with ineligible companies to disclose.

Further teaching from Dr Zanlorenzi can be found here: https://app.medall.org/p/ricardo-zanlorenzi

Learning objectives

1. Understand the importance and benefits of awake tracheal intubation, particularly for patients with difficult airways or trauma patients, and recognize it as a safe alternative to video laryngoscopy or direct laryngoscopy. 2. Develop effective communication skills to adequately explain to patients the rationale behind choosing awake tracheal intubation and obtain informed patient consent for this procedure. 3. Become familiar with the five main steps of awake tracheal intubation, and understand why performing them in this particular order may increase the success of the procedure. 4. Recognize the significance of global trends indicating decreased use of awake tracheal intubation and understand the potential dangers associated with ignoring this technique. 5. Leverage knowledge from literature evidence and professional resources such as the National Projects, the Difficult Airway Society and various anesthesiology societies to make informed decisions on airway management.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Perfect. So we're live now. Um Hello, everyone. Thank you so much for giving up some time to attend medical education session. This is part of the anesthetic sessions that we do and it's called Steps for a successful awake tracheal intubation. And it's by Dr Ricardo Zanzi who is an anesthesiologist from Brazil and is very passionate about intubation and I'll let you take over. Thank you so much. Thank you via, thank you everyone for being here watching this class. So my name is I'm from uh Brazil. I'm based in, at Joinville. It's a city in the south of Brazil at the moment. I'm not in Joinville. I'm in Florianopolis. The names. I think you might think it's a little bit strange, but we're gonna discuss uh a subject regarding ra management that I think even for anesthesiologist, it's kind of uh tricky and I like to put in this way like steps for a successful intubation. Because if you think about this step by step and if we do this kind of the same way, every time we're going to manage an airway in, in this way, I think it's easier for us just to adjust something or other to each of the, the, the details of each patient and you don't do like uh every time you do in one way and this, this way you can forget something, right? So let's go on here. Oh, for first of all, uh I would like uh before my disclosure, I'd like to thank you for the opportunity of sharing this, this knowledge with you. And I rece I get some uh devices from some uh companies here in Brazil. But anything that is going to influence what I'm going to speak here. OK. So who am I? So I'm anesthesiologist here in Brazil. In Brazil. You have to be a doctor to be an anesthesiologist. So only doctors do anesthesia here in Brazil. I'm the actual president of Original Anesthesia Society from my state here that is Santa Catarina. I work in an anesthesia group or company that we say here in Joinville. And I'm the founder of this school here that we naming Portuguese is called A and in English, it's like in a free translation, it's airway school and a member of these societies here that are societies for Airway Management. That's all we, all my updates regarding airway management usually come from. So you must know like this, the, the difficult airway society from UK, the s the Society for Airway Management that it's kind of the, the, the, the American one and the European Airway Management Society. OK. So every each and every one of you, you can remember as doctor or residents or other healthcare professional of these societies and often they have um some kind of discount for low income countries. Ok. So it's pretty interesting. So let's begin our lecture. So I don't know those of you who haven't uh heard about it about the NE four. So in UK, the Royal College of Anesthesiologists of UK, they have uh initiative that is called National Projects. The last one was the N EP seven which previously I gave a lecture. I had a lecture uh on Tuesday about it because I love the Neps. And this one is the hugest, the biggest airway management uh public uh publication that we have until the moment it's from 2011. But we have a lot of uh information that we can get yet from this. OK. I'm not going to, to get the details, but I'm going to focus on some findings that can get us some reflections about our subject here. So we are going to see these QR code, you can put your in your cell phone and access uh for free this document. OK. So in one of the summaries of the net four, we have that the project net four identified numerous cases where awake fiber optic intubation was indicated but was not used. OK. So this lead usually to some adverse events and the commonest, commonest cause of events that were reported on that four was a poor judgment. So if you don't judge adequately an airway, if it's difficult or easy, even being anatomically or physiologically, you cannot indicate the right way to manage it. Ok? OK. You're talking about the intubation. But now I have a video endoscope. Why should I get uh awake, choose and awake for intubation if I have now aves cope that solves most of my problems. So I have here some publications. OK. So Cockran reviews editorials uh guidelines that say that comparing to the direct laryngoscopy, we know that video Lagos it's safer. You have first best success higher than the uh direct laryngoscopy. You have less hypoxia, you have less esophageal intubation. So it's better. OK. Uh even most importantly yet for the for difficult predicted difficult airways, we know that video laryngoscopy, it's really uh superior and better than direct laryngoscopy. So we have here failure intubation rates. They are pretty uh less than uh the direct laryngoscopy. OK? But we still have them. So this is not the perfect device. There will never be a perfect device that is going to solve all our problems. The secret is to know to how to choose the best device to use on that patient in that situation. OK. So that's, that's our responsibility to to to to train and to be trained uh to know how to use the best the the devices. OK. So we still have the possibility of failing in the video laryngoscopy. OK. OK. Ricardo. But what about videoscopy and await track intubation? We know that video endoscopy its better than uh conventional direct laryngoscopy. We don't have this yet on literature. We don't have this evidence yet. My gift is not working. Uh So we don't know if uh video endoscope is better than uh awake tracking intubation even though we can use videoscopy for await tracking intubation. OK. So we have here some statistics here. I first of all, before the steps, I wanna convince you that you should know how a intubation because it's safer for patients. Ok. So we have this doctor Iron that it's the the the now the president of the difficult society. I got this from one of his classes. I don't remember which one. I took a prick screen. OK? And now I'm sharing with you because it's really a nice job he he has done and we have the incidence of difficult mass ventilation here, difficult intubation, failed intubation can intubate, can oxygenate front of max access and that you have the incidence for all patients we have. Now the incidents for the patients that have difficult airways look how you get worse. Here you go for, for traumas. One in five patients is going to have a difficult face mask vilation if you have this predicted difficult intubation. One in four and you have the the chance of can intubate can oxygenate. It's almost 1%. Ok. And in await tracking intubations So why is track await tracking intubation such a safe technique because you won't have the difficulty of face mask ventilation or intubation. Ok. Because the patient is gonna be lightly sedated. Ok. But he's going to be maintaining his consciousness and his spontaneous ventilation, right? But Rica Ricardo, what's the point about failure intubation? It's, it's, it's higher than the other ones because we have uh a number uh uh uh um a small number of awake intubations. So as we have a small number in the denominator in the nominator, every number we put is going to be more represented. So if we have like 100 awake intubations, if you have two failed, you have 2%. OK. Here you have like one, 100,000 intubation. So for, for having 0.36 it's easier. OK? We don't have the number for death but we have pretty slow. Uh Sorry, there are no uh not uh pretty less uh scenarios of can intubate, can oxygenate and situations where we have to do a front of neck access. OK. Coming uh a little bit more updated with the numbers. This is an analysis of uh the difficult airway database of the DS. OK, published by Professor Carin L Bradley. So he, he brings us that the primary plan for anticipated difficult airway is not await tracking intubation. It's direct laryngoscopy, video, laryngoscopy, super airway, uh bronchoscopic intubation under anesthesia. OK. But we have only 10% that does uh awake intubation in this other prospective study that is from the same year 2022 we have the same here use of awake intubation, video, laryngoscopy and high nasal flow oxy oxygenation is uh were uncommon even when predicted difficult airway patients. So we have a, a rate of 2.7% even less than the 9.9%. And this here we have this uh this paper published it in 2023 of in the Canadian Journal of anesthesia that takes for us, it's a cohort that brings from 2014 to 2020 the number the rates of a tracking intubation cases. And we can see here that, oh, sorry. And we can see here that it is getting a little bit slower throughout the time. OK? The it's, it's happening a little bit less. So we see here in 2014, we get like 1% 1.2 that it's the the common number throughout the world. And then in the era of video laryngoscopy where we are having more and more video laryngoscope available. We can see that it's getting uncommon and this is dangerous because it's still being the safest way to guarantee to manage an airway that is predicted to be difficult. Ok, Ricardo. But what about the steps? Ok. What about the steps that you told me? So let's talk about the steps. It's going to be five steps. OK? This is not something fix it. But it's nice that you do in this, in this order because it's, it's gonna be easier for you. So the first of all, and the most neglected, it's the step one. What is the step one? The step one, it's the consent and explanation. And then you might say to me, well, of course, I'm gonna consent and explain everything I do to a patient. I have to get the consent and I have to explain what's gonna happen. Ok. But this is a, a little bit different. Uh I don't know how, how is the, the in the country you, you leave. But here in Brazil patients still have a lot uh are really afraid of anesthesia. And after COVID, they are like, they, they know a little bit more uh about intubation and they have seen a lot of relatives maybe dying because of COVID and it was related to the act of intubation intubation. So they are really afraid of intubation. Ok? They usually don't know the, the, the term airway management, but intubation they are usually afraid. So if you say to a patient that maybe is going to do an elective surgery, uh that is going to be intubated, intubated awake, he's going to look at you and say, are you kidding? Like a a are you, are you really going in to make me awake? The best part of anesthesia is to be sedated and to sleep and you're going not going to do this to me and you are going to put a tube in my throat with me awake. So this is where it comes to you to explain the patient about safety. First of all, you are not going to put force a tube into his throat with him awake, you are going first of all to explain why you are doing this. People understand safety, ok? And uh this is something that Doctor William Rosenblatt says, and this is really interesting because he was the first one who taught me these steps. I watched him uh uh uh Doctor William Rosenblatt is a Yale professor in the US. And uh he's, he taught me these steps at a course that he, he, he, he, he, he presents in, in sometimes pre pre congress or pre event or after or in some specific uh specific schedule that is called airway on demand. If you put this on youtube, there's a lot of videos about him about him doing endo uh flexible endoscopy. And he's really did that. He explains a lot. He, he gave me one or some, some of the of the slides during the, the, the course that II use some images here. And he taught me these steps and I II kind of changed adapted some of them. But he says something that's really important. That is safety first. Always say who went to Disney, who know that uh Disneyland uh say safety first always and that's what we need to say to our patients. Everybody that goes to a hospital, they want to be safe, they don't want to be harmed. And this is why you are doing an a weight drop intubation, your patient because it's the safest way to manage his airway because of what you saw, what you saw on exams, what you saw in your physical examination. Ok. And people understand safety. After you said, you told him, explain to the patient that this is for safety. You explain exactly what you are going to do step by step and that the patient is free to stop at every moment. If he raises his hands, you are going to stop everything. You're gonna, you're doing, you are going to leave him, give a deep breath and then you continue. So the patient has to trust you and the patient has to be comfortable that you are not going to force him to do anything. Maybe this is one of the mo the the most important steps. OK? Because here is where we create a, a medical and patient rel relationship. And as an anesthesiologist, I can say that uh uh maybe I'm not used so much to these because sometimes we s we we, we get to know the patient in the day of the surgery and then you talk a little bit and put them to sleep and we are not used to create this relation. So this sometimes to some doctors might be a little bit difficult, but this is really important for the patient to collaborate. OK, during the intubation, because you're going to need his help to accomplish this intubation. OK? So this is the first step step. OK? I don't know those of you who watch and go back to the future. I like this and I like to illustrate it in the lights too, to not be so boring like this like a usual class. So this is Margie mcfly. He's in the future. At that time, the future is 2015 and he has a jacket that dry itself is and that's what I wanted to happen with the mouth. So the step two, it's all about drying. OK? What is dry? Why I want to dry here? This is a local anesthetic lidocaine. OK? And this is the Brazilian version. OK? That uh the, the commercial name here is Cine but it's lidocaine 2%. So what happens when we put lidocaine to anesthetize to do the, the local anesthesia to provide an adequate uh anesthesia for intubation, uh awake intubation, the local anesthetic, it's toxic for the mucosa and for the nerves. So what happens? It's as a mechanism of protection, we begin to have a lot of saliva and secretions and that will dilute your local anesthetic. So you're going to have a, a lower concentration of. So if you are applying a 2% lidocaine or, or a 4% lidocaine you're going to have in the end a 1% lidocaine and you're going to, it's going to create kind of a layer over the mucosa that's going to be difficult to penetrate in the mucosa and to effectively topical the airway. Ok. So that's why we need the mucosa and the airway to be dry. So, step two, it's drying. Ok? And how do we do it? We do with agents that do this uh drying of the mucosa. We have some contraindications here. I'm going to, to, to, to, to take, to use to the options we have. So one of them is the closed angle, glaucoma and arrhythmias. OK? For use of these agents. So this is an example of an array you can see here, epiglottis. OK? And down there is the glottis. So this is an array that is not dry. Oh This is this is the aet noise and the vocal cords. I'm gonna play it again. OK? So if you uh if you touch anything of these with your video, you're going to see only bubbles and anything else. So this is not AAA good way to, to, to perform and await for intubation with all these secretions. OK. So what are the options we have for these drying agents that are called the anticholinergic drugs? We have usually three options in this class. We got atropine, scopolamine and glycopyrrolate, glycopyrrolate here in Brazil. We don't have it. OK. So I never use it but outside Brazil, I know that's really common to be used for this. Propose. Ok. Uh, you see here that what are the, the main, uh, actions of these, uh, of these agents and what I use here in Brazil. And I don't know, II think it probably available in every country. It's the scopolamine because it's the one that has the most effective action as an anti ciao agent. That's what we want sedation here. I never seen like a really huge sedation with this drug but it, it, it, it crosses the hematal barrier and it increases less, no, not increases so much the heart rate. If you don't do it as a bolus, that's the importance you can do do this as a b. The idea is that is that you put like 10 or twe 10 or 20 mg in uh 100 mL of a saline and then you like put it in the patient in a vein like in 10 to 20 minutes or 10 minutes, it's ok. And then the patient is not, not going to feel the side effects of this, ok? And the patient is going to be with his mouth and airway dry. So step two, take home messages. You cannot do this as a bolus. You have to dilute it in like 50 100 mL of saline or other crystalloid and put it kind of slow 5 to 10 minutes. Otherwise, the patient is going to feel kind of sick and it's going to feel tachycardia and then the the chance of collaboration uh is going to to begin to be compromised. Ok. So step one consent, OK. Step two, driving, step three, nose preparation. Well, what the hell is he talking about nose preparation people? So what we have to do in everything that we do regarding airway management is planning? Ok, we got a plan. So why do we prepare our nose here? We prepare the nose because we have to have a plan B. So maybe if the patient has an exacerbated uh huge gag reflex, even if you did an awesome uh topical, topical organization of the base of the tongue. Uh and the patients still having a gag reflex. So this is maybe an indication for using a NASA route if you don't have any contraindication. So we have here, the NASA, this is the nostril and you see that always the, all the, the, the, the the ways here they lead to the nasal FNS. And then you see, so we have some contraindications here to use the, the, the NASA Ro that it's sis a kind of co coagulopathy, tele inject a pregnancy kind of uh anatomic obstruction in the facial trauma. I will not recommend there's not a formal contraindication, but it's not recommended because we don't know the the kind of facial trauma. So what we will use here, we, we are gonna use a uh a, a vasoconstrictor oxymetazoline. OK? So here it, it's a normal mucosa, OK? And now a mucosa with the use of a vasoconstrictor. So we see that the way has opened, you see that, that it, that's really uh vasoconstricted mucosa. OK? You can see that uh it's white because you have a huge vasoconstriction here. OK? So you can open a ray, let's let's get back here. So you see it's difficult. There is a lot of mucosa. If you stay like touching it, it might bleed and this is not a good, good thing. And after you prepare the nose, you might have a better way to cross the, the all the the the structures inside the nose. So this is a video for doctor from Doctor Rosenblatt. It's not on my video. So it's pretty simple. I prefer to turn this and prefer to ask the patient to get to flex the neck and put it some a little, not, not so much, not like uh not, not, not, not AAA big dose, ok? Because if the patient is hy hypertensive, uh the mucosa is going to absorb it and the patient, it's, it's an alpha one agonist. Ok? So we have to take care with these medications, ok? But if you put like some drops in like 23 do drops in each nose, in each nostril, it's, it's pretty ok for you to, to leave the, the, the nose preparation. Ok? So plan for failure. So the nose preparation here, it's thinking that your number one, your plan a and a weight tracking intubation might not work. So that's why you're preparing the dose. I might not use the nose. But if I have to use it's already prepared. OK? I don't have to stop and put the, the oxymetazoline and wait for it to make uh it effect. OK? So always thinking ahead. So step one, let's always remember here. Step one, we got the consent and explanation. Step two, we got uh the drying, not drying agent. Uh step three, nose, preparing, step four, sedation. OK? Or anxiolysis. I don't like sedation because I like the, the, the minimal sedation. OK? So this is Doctor Anthony of a SAPIEN. Uh I didn't get to know him or meet him. He uh died in 2010 and he's like an authority in awake intubation and endoscope guided intubation. Uh Some of the people here in Brazil that taught me uh awake intubation had spent some time with him and brought some of the in Chicago and brought some of the knowledge here to Brazil. And, but he's really an authority and someone that uh and had a lot of experience using this kind of uh management. So what he says in how his experience and knowledge is that and I totally agree the patient should be lightly asleep if unstimulated, but responsive to commands and able to carry out simple instructions So the patient should be comfortable, maybe a little bit sleepy. But if you ask him something, he must be solely able to carry out these instructions because it's a procedure that the patients collaborate. Ok. So Ricardo, what do you use in your sedation for aw intubation? So I use usually if the patient and doesn't have any contraindication or isn't really like more than 65 or 70 years old, I usually use a small tiny dose of benzodiazepine midazolam. Why? Because of the anxious disease and amnesia? Not because of the sedation because the two doses of midazolam like half a milligram or 1 mg depending on the weight of the patient is enough to give him amnesia or anxiolysis. OK? That's my objective here with a Benzodiazepine and I have the flumazenil. OK? I have a reversal agent, right? This is important. Propofol propofol has up fast in initiation time. OK? But it has no analgesic properties. And for you to get amnesia with Propofol patients should be asleep pretty deep asleep. So has no reversal agent. I don't like in bolus, not even think about it in even in continuous infusion. I don't like it. Ketamine, ketamine for awake intubation. People remember we need collaboration. We cannot have a dissociated patient here. OK? 1020 mg of ketamine might associate my patient. I don't want it and I have uh a huge amount of secretions because of the side effect of it. So you, you will not be able to have the cooperation of the patient. So you can have, I, if you want to do, uh, spontaneous ventilation, sedated intubation, you can use cabin, but a wait for you intubation with light sedation and topical anesthesia. It's not a good option. Ok. Dex Metomidine. Well, this is a good option. Ok. It gives it dries your mouth, the secretions, it gives you analgesia and sedation as a side effect, especially in bolus hypertension and bradycardia, but has a time to initiate its action a little bit longer. Ok. And people using dex maritidine, I see, they rely much on the analgesia and sedation, uh, for the intubation. Then in the local anesthesia they do. And I think it's the opposite. I think you cannot never rely on sedation. You gotta have the sedation or the disease and comfort and then you do a pretty good topical anesthesia. But if in some way, you cannot have like a good topical anesthesia for some reason that I think it's always kind of impossible. You can use like a little bit higher doses because you don't have the depression of the ventilation here. Right? But always put this on mind. Ok. It's not about the sedation, it's about the sedation of the patient. You have to seduce him that you are, you are confident on what you're doing, you know what you're doing and he knows that you are doing the safest, uh, array managed for him and the other drug that I use. So I usually use benzodiazepine if there's no contraindication or the patient is not much old and an opioid fentaNYL and midazolam, they are really widely available. So in a really small dose like 50 mcg or sometimes less than eight, take care with the synergic action. OK? Between the benzodiazepine and opioids, you have a reversal agent here. OK? This is a, a nice, so something nice too. But now as an anesthesiologist and having a wide availability of this, that is the remifentanyl, I usually use a tiny small dose of benzodiazepine and I titrate the remifentanil to the effect. OK. So this give me a really uh control of the situation because if in some way, patient is a little bit deeply sedated, I can get down the infusion dose and then the patient wakes up because the contents con con context sensitive, half lifetime of the remifentanil, it's really small. Ok. So if you're an anesthesiologist or you have the availability of this drug, it's a good option. So some take home messages of this important step. Never, never rely on sedation. You are doing an awake tracheal intubation, not a deeply sedated, tracheal intubation. Ok. Take care with the synergic effect of the drugs, ok? You are, if you begin to mix a lot of drugs, the patient is going to uh sleep, ok. Titrate the doses to the effect. OK? Go in and liquids, OK? And always maintain the patient cooperative. This is really, really, really important. OK? Otherwise you are doing something that is not awake track intubation. You are doing a sedated, tracking intubation, you are doing something different. OK? This is not what I'm, this is not me that is defining this. So this is maybe the authorities that in every management that came before me taught me. And now I'm trying to share this this knowledge. So let's go there. Uh First of all, step, one, consent and explanation, step two, dry, step three, nasal preparation, step four. So today is showing all this is amnesia. Step five. Now we got the, I think what everybody is waiting for that. It's the uh local anesthesia for management for a for intubation. So first of all, we have to have some uh concepts in our mind here that what it's the innervation of each of the areas here. So the laryngopharynx, it's innervated by some branches of the vagus nerve, the oropharynx and especially the base of the tongue by the glossopharyngeal nerve and the nose by some branches of the trigeminal nerve. So what we're going to see here. So there's another image from my, what we're gonna see here is uh specifically what is innervating each of these areas. So the glossopharyngeal nerve is going to innervate vallecular in base of the tongue. This is responsible for the gag reflex, the vagal nerve that for an or oral tracheal awake intubation. Uh we need to anesthetize only this sh not necessarily the uh the trigeminal nerve. OK. So we have the superior and the laryngeal branches. OK? And even these two have some divisions here. OK. So if we anesthetize all of these here, we are going to anesthetize all of these here. OK. But you can do uh if you want, right? If you want, you can do the specific blocks like I'm going to block the superior laryngeal nerve or the recurrent laryngeal nerve. But it's a little bit uh more challenging for us to be able to do this. OK. So we know what we have to block. How are you going to do this? So when I was in my residency, there was some questions about why, why don't we just put in some lidocaine or here we have benzocaine and nebulize it. So why usually this doesn't work or when it works. It takes a long time for this way because of the size of the molecules. Sorry, this is in Portuguese, it's micrometers. OK? Micrometers. It's uh it's in Portuguese, I forgot to translate here. So these the the the molecules, the particles of the nebulizer, it's they are the size of 2 to 5 micrometers. So they are made to go in in in the deepest uh parts of the tachy bronchial tree, right? And the atomized particles, they are made to go to the upper part of the airway of the trach bronchial tree like until the carina that is exactly where we want them to reach, the size of them are 100 20 to 200 micrometers. OK. So you got a, you got a that he's nebulizing. You can see the size of the particles here and this disease and atomize it. Can you see the difference the, the, the size and the, the, the weight of these particles, it's really bigger. OK. So this is one of the things like one of the things that we can use. So the atomizer. So you might have an atomizer. There's a lot of ways here in Brazil, we have mostly uh only the one that is the magic from Teleflex that you can mold him. Uh And you can have uh some homemade that. It's the mckenzie one that you get this three way here. You put the oxygen or air 2 to 3 L per minute. A syringe with lidocaine here in order and a 20 gauge uh catheter in order and you're going to atomize slowly, OK? You can, you're, you're going to have the kind of the same effect. OK? Uh You can put like some jelly lidocaine jelly here. This is an of a saing can that you use for uh awake intubation using a fiber exoscope. You use this because you don't want the patient to uh smash the device as you use for endoscopy. OK? You can have a tongue depressor to put the lidocaine the jelly in the base of the tongue. OK. And you asked me why in the base of the tongue? Because it's the to the topography of the uh glossopharyngeal nerve. OK. But we're going to see the, the, the blocks in a, in a way here. We're gonna see the options we have. So this is the mckenzie atomizer. It's a homemade one and just a moment, this is the basis past. So, uh I don't know the, the ones of you who know Jack Base Jack Pa is the inventor of the GlideScope, one of the first laryngoscopes. So what he in, he invented this space for uh sorry for anesthetizing the airway. So the here in Brazil, this is the options I have. So we don't have 4% lidocaine. OK? That you might have in Europe or other countries around the world. We have only 2% lidocaine. That is 20 mg per ML or 10% lidocaine as a spray, these 10% lidocaine people. It's 100 mg per milliliters. So many people ask me, what's the, the, the, the toxic local anesthetic dose for this mucosa? It's around 9 mg per kilo. OK? It's a lot. OK. So if you reach like around 6 mg per kilo during your local awake in to anesthesia, we are probably doing something wrong. OK? Because the, the, the, the airway should be anesthetized already. So I have these options here and with this, I can anesthetize uh it has a low cost, OK? Just like one time uh easily the airway. So one option is to use this device here that it's homemade. Uh that is the space is past. So what you do, you put 7 mL of 2% lidocaine and 3 mL of air, OK? In one syringe, 10 mL, the other syringe, you put 7 mL of lidocaine 2%. But now the jelly the ointment, OK? And 3 mL of air, OK? And then you mix both of them like the bubble test. You see to, to, to see if there is an patent uh oo for OK. Uh And then you mix them, uh the solution here, the mixture is going to be uh a little bit, not so uh not such a, not so dense uh mixture that's going to have some air bubbles that when you put in the base of the tongue and, and in the airway, it's going to go down to the throat and it's going to anesthetize all the way down until the ano and it's not going to anesthetize the trachea, but all this way down, it's sometimes better than the only the jelly. OK. So how do we anesthetize for an uh uh nasal intubation? So after you prepare it with the vasoconstriction, you can put some jelly inside the nose and ask for the, the patient to uh uh to deep breath, take a deep breath, you can put 10% lidocaine so to anesthetize the nose that your nerve is not difficult. But the, the, the, the chance here is to, to anesthetize the base of the tongue. OK. Usually the gloss pharygeal nerve it's passing through here. OK. So in this topography here, so you, I usually do some three sprays of 10% lidocaine here. Three sprays here that three sprays are a low dose. It's not more than uh in each side. It's not more than 1 mL 100 mg. OK? Usually this will be enough to anesthetize all this region here, including the base of the top. If it's not enough, you can put some ointment of lidocaine here in the base of the tongue and you can hold the tongue of the patient for him to not swallow it because even if you have 4% lidocaine, you gotta leave it like for 30 seconds or one minute uh for this to, to act, OK? After you have the gloss pharyngeal or the trigeminal or both of them anesthetize it, you gotta anesthetize the v, the vagus nerve. OK? And then you have all the branches here, you have the thyroid cartilage, the cricoid cartilage, the higher b and you can do a block the superior laryngeal nerve that is directed here. Then with the, with a local anesthetic like a direct block that you like put your, your needle direct to the higher bone. He's passing just beside the higher bone. I never done this, I ne I don't think it's necessary but it's really effective. Ok. I usually do. I don't put like this because he's thoracic just going from Costco. And you, you know, the patient now is sedated and you not coughing. But what you should do is to tell the patient you are going to cough and you, what you should, what I want you to see here is that you palpate, ok? And then you insert you, you aspirate to see if there's bubbles in 5 mL of lidocaine. He's going to come and he's going to throw all that lidocaine up to the airway and he's going to anesthetize vocal cords area, nos and the upper trachea, this other, you can see the, the, the, the, the blood that we see, of course, it's higher than it's released. Uh It's bigger than it released from the, the puncture of the needle in the. So you can see it's not, not mean anything down the car for an OK. So it's really effective way of anesthetizing the vagus nerve. So for the ones who are afraid of maybe perforating the trachea and perforating the esophagus, I can say that the cric cut cartilage, it's a complete ring and the posterior part of the car, the cartilage car, uh the cric cut cartilage, it's really bigger. It's huger larger than the f the part in the front. So you have a shield here, you're not going to perforate. OK. So don't worry about it. So, what are the, the, the options we have here for anesthetizing? Now, the, the, the airway? Ok. So we have the 10% lidocaine. You have the pa past, you can use a tongue depressor or a swab, uh, where you can put uh, the pa past or the lidocaine jelly or ointment. You can use the mckenzie that it's uh, uh, er, that is adapted. You can use the mucosa optimizer that you have many brands in anything and you can use the spray as you go. If you're using a flexible endoscope, you use the, the, the channel of the endoscope where you can put oxygen or you can put, uh, or can aspirate secretions, you can put lidocaine through that channel or you can pa uh, you can insert through that an epidural catheter and you can put a lidocaine through that epidural catheter. Ok. He's not a situation that I've done this is that, uh, has already been uh awake for many times. She had a lot of cancer and neck ready therapy. So II didn't have the flexible scope available there. So I decided to do an awake with an hyper angulated blade using a videolaryngoscope. So you can see here the, the, the few that I am having the fi Lagos cope, you can see that I'm doing a lot of far here. She's lightly sedated with her. I'm getting and I have already anesthetized the base of the tongue and now I'm going to anesthetize the vocal cords. She's going to cut. Ok. You're going to see there's going to be a move. I'm going to anesthetize all the vocal cords here has got, this is a positive thing. Hey, I'm in the right place, right. Uh I'm going to anesthetize uh the vocal cords because I cannot make anything in this neck because if I try to, I cannot, I, II couldn't even palpate the crico membrane because it was all one thing here in her neck because she had a lot of surgeries there. OK. So I'm going to have some difficulties inserting the tube here using just the Fosco because do the inferior airway. OK. And um the right was, was being used and then my colleague uh helped me doing an external or maneuver. OK. These are the vocal cord. The are no, and now I could reach the airway function. It's slightly sedated. OK? You can see by the movement of the, of the, the area that and I have to because you have a, I'm talking to her before. But I mean, this is important. So this is one example that it's possible to do. And this is me, this is me in my third year. Uh You can see I'm different here and my third year of anesthesia uh residence. And I got this uh this fibroscope for uh doing uh my conclusion uh residence, conclusion work uh studying some mascara and then I did a topical anesthesia and I decided to intubate myself. OK. So I did a top interpreter the way I taught you. OK. So there is my carina here. Uh And then I'm trying to put my tube on myself. There's some saliva here because I didn't use the drying agent because I have no vein. OK? And uh I'm trying to, to, to insert the tubes. So I think the tube was uh 8.8 0.5 to use it. OK? And no, none of my colleagues here was helping me to use it, but I was successful and, and I have no like gaggle or pain. Uh It proves me kind of laughing here. It's like residents doing things that I shouldn't do right? But uh it's to show for you that it's really possible. OK. So folks take home message, step one that it's the consent and the explanation and the step five that it's the local anesthesia are the most important ones. OK. Uh Remember this, please. Other things, please. If you have doubts about what devices using or something. Go on youtube, awake, track you intubation, you're going to see a lot of techniques. A lot of crazy guys doing awake tracking intubation on the on themselves. It's pretty interesting to watch and I would like to leave this last uh phrase here that it's from our doctor when planning and await intubation. The patient typically require, require less midazolam than the anesthesiologist and why I would like to leave it because the mo the, the, the most often we do this, the most confident we get on doing this. We're going to do this fastest in a way that's easier for us and for the patients. Ok. So if we don't want to practice because we are afraid or we don't know how to do this, then we're at the time that maybe we know that it's indicated to do it's going to happen exactly what happened in the ne for that. The patient, the people, the anesthesiologist know that it was indicated, but they don't do this because they don't feel safe or they don't, don't feel comfortable and you put patient in risk because of this. Ok? So if you have any questions or anything you want to ask, I am available, I hope you, I hope you, you like the, the presentation here and can you, uh, Tanya has asked it here if you can give, uh, nausea medications, uh, it's not going to work. Ok? If the patient is having a gag reflex, if you have, if you give him, um, on Theron Palo Noron or Droperidol or anything, it won't be enough, uh, for you to get this less. Ok? And even the, the, the on scopolamine is something that can help you in this prevention of the nausea, but it's not something that it's present on literature. Ok. Taa, it's usually something that we don't do as a prophylactic agent. And the most effective is a good anesthesia of the base of the tongue. And the, if the patient has still have something that is really uh ii it's really difficult to control like a, a gag reflex that it's really exacerbated. The recommendation is to use the, the NASA route. Ok. Let me see if we have any questions here. So feel free to ask if any, anyone has any other questions about anything that you might might need. And as I said, practice and I would like you to uh search on youtube, OK? Search on youtube for a track intubation. Uh You're gonna see some videos and see this class again. OK? You're going to be able to get some insights and whenever you have doubts, I'm available at Instagram at via me education here. I'm available for you to, to get your, to get your, your doubts here. OK? Thank you very much for, for your presence and for the opportunity of, of teaching all of you. Thank you so much. That was brilliant. And the, the videos were fantastic. I can imagine. So some people that are not from the, everybody here is from health care uh area. But like when I show to my friends or to my mom, she like gets crazy about it because they are not use it. But it's something as I said uh for common people, II use these videos sometimes to show to patients. Ok. So this is possible I've done this to myself. This is for you. Ok. It's, it's, it's safer for you. So if you convince the patient that it's the safest way for him to go through that procedure, the patient is going to say, ok, thank you for, for telling me this brilliant. Um In which case, there doesn't seem to be any more questions, please do fill in the feedback and follow medical education for more events like this. Um And as Ricardo said, you can contact him, is there are there any details you'd like to leave for people? Yeah, II can I can leave you my ins Instagram here because it is, it said that because everything there is in Portuguese, you know, I've got it's called the V area. This is in Portuguese. But, but if you, I I'm going to I show many, many video, real videos there. Uh I'm I'm in a week that I'm discussing surgical airway, so I put some videos there. So if you want to follow me there and if you ask me in English, I can uh answer you on English as well. So I'm I'm available for you. Brilliant. Thank you so much. Um I think we'll end it there.