- Direct laryngoscopy and oral intubation most frequently performed:
- Muscle relaxation generally used
- Ensure smaller tube available if tracheal compression
- If difficult intubation predicted:
- Awake fibre optic may be used – risks ‘cork in bottle’ phenomenon in setting of external compression
- Gas induction previously described but limited data
- Ensure rigid bronchoscope available in case of ‘can’t intubate, can’t ventilate’ (CICO) situation – cricothyroidotomy may not bypass obstruction
- Options for tracheal tube include:
- Nerve Integrity Monitoring tube (NIM):
- Allows intraoperative monitoring of recurrent laryngeal nerve
- Recommend by NICE
- Reinforced (flexi) tube
- Nerve Integrity Monitoring tube (NIM):
- Consider head-up tilt during induction to avoid possibility of tracheal compression on lying flat
- Ensure adequate pre-oxygenation given risk of slower than usual intubation:
- Consider use of high-flow nasal oxygenation
- Tracheal tube should be positioned away from surgical field
- Consider spraying cords with lidocaine to reduce coughing
- Cuff should not be overinflated to avoid laryngeal oedema
- Be aware of the presence of a ‘shared-airway’
- Tracheal tube should be positioned away from surgical field
- Ensure tube securely taped
