Episode 28: Airway topicalization with Dr. Laeben Lester

In this episode I welcome Dr. Laeben Lester to the show.  Dr. Lester is trained in Emergency Medicine and Anesthesiology and has completed fellowship training in Cardiac Anesthesiology.  He shares with us his “Nearly Needleless 5-Step Approach” to airway topicalization for awake intubation.

4 Replies to “Episode 28: Airway topicalization with Dr. Laeben Lester”

  1. Just wanted to comment that I have actually witnessed a cardiac arrest from neosynephrine nasal spray. The patient was a down syndrome 20 ish year old for oral surgery and nasal rae intubation. Was not my patient but I helped with the code process, HR in the 20-30 before arrest and BP 200+/100+. So I always use afrin now, just in case…

    1. Great point Jennifer. Thanks for sharing that story. I also prefer afrin and I think if you have it it makes sense to use. No real downside and probably safer.

      Best,
      Jed

  2. I cannot tell you how helpful the LMA is as a conduit for awake fiberoptics (and asleep i.e. Cervical spine issues).
    The frigging LMA puts you right at the cords almost every time, and when you can place the LMA, you know topicalization is adequate. Also, this gives you a straight shot to fire some local on and through
    The cords for pts where transtracheal block is difficult (i.e.-most awake fibers; although consider ultrasound to help with transtracheal block-learned it on YouTube and very easy). Sometimes you need to pull the LMA back slightly to have enough room to flex into the cords. That way you have a way to ventilate also if you are struggling to get in and bypass all that soft tissue (as opposed to oral pink airway where u still need good jaw thrust, etc).
    Also always sit the patient upright and face them! You use gravity to get all the soft tissue out of the way and you can see the monitor, and it is more comforting to them by far. It doesn’t matter things are backwards-you just flex the opposite way if you do it wrong which always happens to me.
    Precedex, precedex, precedex. Last time I did it, had the stablest vitals I’ve ever seen. Don’t load too much w precedex (maybe 0.2-0.3/kg over a few mins instead of 1 mcg/kg over 10); less hemodynamics issues if u skip that big loading dose). And I’m starting to use much more glyco in general to dry secretions (just squirt it in the IV bag to avoid too much tachy) for the benefit of a dryer emergence; so obviously paramount for AFOI.
    Thanks again Jed.

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