LARYNGEAL SPRAY

AWAKE INTUBATION

› If a difficult airway is anticipated intubation should ideally be

done under regional aneasthesia.
› This allows the patient to breathe spontaneously, maintain
airaway patency, and cooperate with the operator.
› EXCEPTIONS to performing awake intubation, such as patient
refusal,young children,and uncooperative patients(confusion
learning disabilities).
TOPICAL ANEASTHESIA
› COCAINE
› Cocaine is the only local anesthetic with
vasoconstrictor properties; therefore, it is particularly
useful for topical anesthesia of the nasopharynx.
› Cocaine is available as a 5% or 10% solution and in
paste form
› the maximum recommended dose is 1.5 mg/kg.
› It should be used with caution in patients with
coronary artery disease, hypertension, and
pseudocholinesterase deficiency.
Continued
› The mixture of 2 mL of 10% cocaine, 1 mL 1:1000
adrenaline, 2 mL sodium bicarbonate, and 5 mL
sodium chloride makes 10 mL of Moffett’s solution.
› This is commonly used in rhinological procedures to
provide local anesthesia, vasoconstriction, and
decongestion. It is also used to topicalize the nasal
mucosa to provide the optimal conditions for nasal
intubations.
LIDOCAINE
› Lidocaine is the most commonly used local anesthetic
for airway topicalization
› The 4% solution and 10% spray are most often used .
Systemic absorption from topical application to the
upper airways is lower than expected, so in practice
higher doses can be used than the recommended 2
mg/kg.
LIGNOCAINE SPRAY
VASOCONSTRICTORS

› Vasoconstrictors should be used when the nasal

mucosa is being anesthetized; this is because the
mucosa is highly vascular, and bleeding can readily
occur on instrumentation, which can obscure the view
seen on the fiberscope.
Vasoconstrictor agents such as xylometazoline and
phenylephrine are prepared with lidocaine to produce
local anesthesia and vasoconstriction.
cocaine has inherent vasoconstrictor properties, so it is
a suitable agent to use for the nasal mucosa.
APPLICATION TECHNIQUES
APPLICATION TECHNIQUES
› The nasopharynx and oropharynx can be sprayed
directly from the container of local anesthetic
preparations, sprayed using the McKenzie technique,
or sprayed via a mucosal atomization device (MAD).
› The McKenzie technique uses a 20-gauge cannula
attached to oxygen bubble tubing via a three-way tap.
› The other end of bubble tubing is then attached to an
oxygen source, which is turned on to deliver a flow of
2–4 L/min.
Setup for McKenzie technique.
McKenzie technique.
› The other end of bubble tubing is then attached to an
oxygen source, which is turned on to deliver a flow of
2–4 L/min.
› As the local anesthetic is slowly administered via a 5-
mL syringe attached to the top port of the cannula, a
jetlike spray effect is seen, which greatly increases the
surface area of the local anesthetic and allows
directed topicalization of the nasal and oral mucosa
Mucosal atomization device (MAD).
› Commercially available mucosal atomizers allow a
similar mistlike effect as seen with the McKenzie
technique by just attaching them to the end of a
syringe These devices are available for nasal and oral
applications.
Mucosal atomization device (MAD).
Administration of nebulized lidocaine.
Administration of nebulized lidocaine
› Adding approximately 5 mL of 4% lidocaine to a
nebulizer, then delivering it with oxygen for up to 30
minutes is a safe and noninvasive way to topicalize the
airway all the way down to the trachea
› It is well tolerated and is a useful technique to
topicalize the whole airway.
› It also allows the topicalization of patients with limited
mouth opening, where atomizers cannot be passed
into the mouth to topicalize the oropharynx.
spray-as-you-go (SAYGO) technique
› The vocal cords can also be sprayed directly with local
anesthetic using the spray-as-you-go (SAYGO)
technique.
› The distal end of a 16-gauge epidural catheter is cut 3
cm from the end and then fed through the working
channel of a fiberscope.
› The Luer lock connector is connected to the proximal
end of the catheter and then attached to a 5-mL
syringe prepared with 4% lidocaine.
spray-as-you-go (SAYGO) technique
› . The distal end should protrude out of the fiberscope,
so that the tip is just visible. The local anesthetic is
then dripped onto the vocal cords prior to the
fiberscope being introduced into the trachea.
› This reduces patient discomfort and coughing when
the fiberscope and endotracheal tube are introduced
into the trachea.
spray-as-you-go (SAYGO) technique
THANK YOU