Episode 8: Topical Thunder - An Awake Intubation Technique

airway management Jan 01, 2020

Episode Summary

Happy New Year! To kick off 2020, we're going to dive into how to approach the patient with an anticipated difficult airway. We'll explore several common airway algorithms, and we'll also discuss the "topical thunder" technique to anesthetize the airway for awake intubation.


What You'll Learn

  • Why don’t we use awake intubation even when its indicated?
  • Which patients should receive awake intubation?
  • What anatomical structures must be anesthetized for a successful awake intubation?
  • What are the advantages and disadvantages of using a video laryngoscope for awake intubation?
  • What is topical thunder?


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Topical Thunder Technique

Step 1:

  • Use an atomizer to deposit 2 mL 4% applied to the oropharynx.
  • Give the patient a break and then retract tongue, go farther down the oropharynx and deposit 3 mL 4% in posterior oropharynx/hypopharynx…patient will likely cough.

Step 2:

  • Place a cm size amount of 5% lidocaine paste on the end of the tongue blade to create a “lidocaine lollipop.” Retract the tongue again and apply the lollipop to the posterior tongue.
  • Let the tongue blade rest on the posterior tongue for about a minute to let the paste melt. Move the tongue blade to the other side after 30 seconds. You may need to remove and replace it as tolerated.
  • The airway may be anesthetized enough for a gentle look with a flexible scope or video laryngoscope (VL).
  • Some cases may decide to proceed with induction & intubation.
  • If 5% paste is unavailable, can use 4% on gauze and place it on back of tongue using right angle forceps or Magill forceps.

Step 3:

  • Prepare either the flexible Scope or your VL and introduce it into the hypopharynx. Use the atomizer to spray 3 mL 4% sprayed directly onto cords and all over the glottic structures and the pyriform sinuses.
  • May need to remove scope if the patient coughs.
  • Load ETT onto flexible scope or have it ready if using VL.
  • Obtain a good view of vocal cords with your scope and spray 2 mL 4% lidocaine into the trachea.
  • Advance scope until carina is in view and advance ETT over scope.
  • Confirm ETT placement in trachea by visualizing the end of the ETT superior to the carina.
  • If using VL, advance ETT through cords after atomized spray of the trachea.

Nasal Route for Intubation:

  • Apply phenylephrine or oxymetazoline to nasal passages.
  • Give 2-3 inhalations with 0.5 mL 4% lidocaine from an atomizer into chosen nare.
  • Apply 5% lidocaine paste on nasopharyngeal Airway (NPA).
  • Advance ETT into anesthetized nare up to 13-14 cm.
  • Place flexible scope through ETT. Most of the time, you will have a great view of the vocal cords.

Preprocedural Preparation Tips:

  • Lidocaine tastes awful.
  • Coughing will occur, but this is good since we know it's getting to the right place.
  • Once anesthetized, the patient may lose subjective sense of airflow in airway.
  • Sedate the patient as needed.
  • The patient should be in the sitting position.
  • You can allow the patient to hold suction yankauer.


Recommended Resources

  1. Heiner, JS. Airway Management. In Nurse Anesthesia. Nagelhout JJ & Elisha SM eds. 6th ed. 2017. Elsevier, St Louis, MO. 
  2. George Kovacs. Podcast 194 – Definitive Emergent Awake Intubation with George Kovacs. EMCrit Blog. Published on March 6, 2017. Accessed on November 10th 2019.
  3. Joseph TT, et al. Retrospective Study of Success, Failure, and Time Needed to Perform Awake Intubation. Anesthesiology. 2016 Jul;125(1):105-14. 
  4. Law JA et al. The difficult airway with recommendations for management – Part 2 – The anticipated difficult airway. Can J Anesth/J Can Anesth (2013) 60:1119–1138.
  5. Kramer A., et al. Fibreoptic vs videolaryngoscopic (C-MAC D-BLADE) nasal awake intubation under local anaesthesia. Anaesthesia. 2015 Apr;70(4):400-6.
  6. Law JA et al. The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: an historical cohort study. Can J Anaesth. 2015 Jul;62(7):736-44.


Legal Disclaimer

APEX Anesthesia Review, LLC and APEX Live expressly disclaim any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party.

Podcast music by Eino Toivanen, kongano.com


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