INDICATIONS
- History of difficult intubation
- Suspected difficult airway based upon findings in history or physical exam, including but not limited to the following:
- Trauma to the airway
- Deep neck infections
- Tumors of the larynx or pharynx
- History of radiation to the airway
- Severe ankylosing spondylitis
- Acromegaly
- Congenital airway abnormality, such as Treacher-Collins or Pierre Robin Syndromes
- Inability to access the cricothyroid membrane, in case emergency surgical airway is required
- Morbid obesity and history of sleep apnea with suspected difficult airway requiring intubation
- Anatomy that otherwise predisposes patient to difficult intubation and difficult mask ventilation while asleep
- High risk for aspiration of gastric contents
- Need for neurological exam immediately following intubation
- Cervical spine instability due to trauma or degenerative disease
- Vertebrobasilar artery insufficiency
CONTRAINDICATIONS
- Absolute contraindications
- Patient refusal
- Allergy to both ester and amide classes of local anesthetics
- Relative contraindications, which may be overlooked in the true emergency situation because the risk of the procedure is less than the risk of hypoxemia or impending loss of the airway
- Infection at sites of local anesthetic injection/application
- Raised intracranial pressure (ICP) that might be exacerbated by coughing
- Penetrating eye trauma that might be exacerbated by coughing
COMPLICATIONS
- Common
- Gagging
- Epistaxis
- Infrequent
- Oversedation (with loss of spontaneous ventilation)
- Inability to pass endotracheal tube
- Laryngospasm
- Hematoma (if invasive blocks have been performed)
- Infection (if invasive blocks have been performed)
- Dysphagia
- Dysphonia
- Inadequate sedation with unpleasant recall by the patient
- Serious, rare complications
- Local anesthetic toxicity
- Damage to vocal cords
- Vomiting (aspiration)
- Traumatic pharyngeal or laryngeal injury
- Bacteremia
- More common after nasal intubation
- In patients with valvular heart disease, prophylactic antibiotic administration before nasal but not oral intubation is recommended
