Combined nebulization and spray-as-you-go topical local anaesthesia of the airway

Background. Twenty-five anaesthetists underwent awake fibreoptic intubation using a combination of nebulization and topical local anaesthesia. Plasma lidocaine concentrations were measured and the quality of the local anaesthesia was assessed. Methods. After i.v. glycopyrrolate 3 mg kg(-1) and intranasal xylometolazone 0.1%, lidocaine 4% 200 mg was administered by nebulizer. Supplementary lidocaine to a maximum total of 9 mg kg(-1) was applied directly and via a fibreoptic endoscope. Nasotracheal intubation was performed once the vocal cords became unreactive. Heart rate, non-invasive blood pressure and oxygen saturation were recorded at 5-min intervals. Blood sampling commenced with a baseline sample and continued at 10 min intervals until 60 min after final administration of local anaesthetic. Subjects graded levels of anxiety, pain and coughing using written and visual analogue scales. Results. Conditions for fibreoptic endoscopy and intubation were good. Seventeen received the maximum lidocaine dose of 9 mg kg(-1). The average dose used was 8.8 mg kg(-1). All plasma lidocaine concentrations assayed were below 5 mg litre(-1). Four volunteers reported feeling lightheaded after the procedure, despite normal blood pressure. Of these, two had the highest plasma lidocaine concentrations recorded: 3.5 and 4.5 mg litre(-1). Twenty-two of the 25 subjects found endoscopy and intubation acceptable, three found it enjoyable and no subject rated it as distressing. Conclusions. This method of airway anaesthesia was acceptable to this small group of unsedated subjects. It produced good conditions for fibreoptic intubation. A maximum calculated lidocaine dose of 9 mg kg(-1) did not produce toxic plasma concentrations of lidocaine.