Awake Fiberoptic Nasotracheal Intubation Research Articles

Awake fiberoptic intubation of a patient with severe multiple trauma in prone position: a case report

BackgroundFiberoptic-guided intubation is considered as “gold standard” of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist.Case presentationA man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient’s recovery was uneventful, and he was discharged from the hospital one month after the surgery.ConclusionsAwake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position.

Comparative evaluation of nebulized versus intravenous dexmedetomidine on intubating conditions during awake fiberoptic nasotracheal intubation

BackgroundThere is a search for an ideal agent to facilitate awake fiberoptic intubation (AFOI). Dexmedetomidine is a selective α2 agonist which can be administered through intravenous, intramuscular, buccal, intranasal & inhalational routes. It provides good intubation conditions without oxygen desaturation but may cause hypotension and bradycardia when administered intravenously. Hence, alternative routes of administering dexmedetomidine which may improve its safety profile are worth exploring. MethodsIn this randomised, controlled, double-blind trial, 46 ASA I/II adult participants scheduled for elective ENT surgery were randomly allocated to Group ND (Nebulised Dexmedetomidine) (n = 23) to receive nebulisation with dexmedetomidine 1μg.kg−1 and Group ID (Intravenous Dexmedetomidine) (n = 23) to receive intravenous dexmedetomidine 1μg.kg−1 before AFOI. All the patients received injection midazolam 1 mg i.v. as premedication before anaesthesia was initiated. The primary outcome was the cough score. The secondary outcomes were the RSS, SAYGO boluses, post-intubation score, hemodynamic parameters, recall of the procedure, patient satisfaction score and any side effects. ResultsThe cough score was significantly lower in nebulized group (2.43 ± 0.992 vs 3.52 ± 1.082) with p = 0.001. RSS(3.30 ± 0.926 vs 4.22 ± 1.126; p = 0.004), number of SAYGO boluses required (2.74 ± 0.864 vs 3.57 ± 1.161; p = 0.009) & the post intubation score (1.48 ± 0.593 vs 2.17 ± 0.778; p = 0.001) were also significantly lower in nebulized group. ConclusionsNebulisation with dexmedetomidine results in desirable degree of sedation and better tolerance of the procedure with adequate attenuation of the haemodynamic responses to intubation.

Comparative study of midazolam–dexmedetomidine combination with propofol for sedation during awake fiberoptic nasotracheal intubation

Aim and objective The present study was conducted to compare the efficacy and safety of dexmedetomidine and midazolam with propofol alone for sedation during awake fiberoptic nasotracheal intubation. The study was conducted on 40 patients of either sex aged between 18 and 60 years belonging to ASA I–II grade scheduled for elective surgery. The patients were randomly divided into two groups of 20 patients each. Group I patients received intravenous midazolam 0.02 mg/kg followed by dexmedetomidine 1 μg/kg bolus infusion over 10 min, and then an infusion of dexmedetomidine 0.1 μg/kg/h and titrated to 0.7 μg/kg/h to achieve an adequate level of sedation. Group II patients received intravenous propofol 6 mg/kg/h bolus over 10 min with an additional dose of 2.4 mg/kg/h as infusion until they were adequately sedated. Hemodynamic parameters, comfort scale values, and patient’s tolerance were assessed. Patients and methods Fiberoptic nasotracheal intubation was done in both groups of patients, and after securing the tube, general anesthesia was administered. Within 24 h of the surgical procedure, each patient was asked to assess their experience with awake fiberoptic intubation. The data were recorded in the proposed proforma, and the final result was analyzed statistically. Results During sedation during fibreoptic procedure (FOS) and ET insertion, pulse rate (P=0.0116), systolic blood pressure (P=0.30), diastolic blood pressure (P=0.326), oxygen saturation (P=0.53), total comfort score (TCS) (P=0.031), and patient tolerance (P=0.023) were observed and showed statistically significant values. Conclusion Dexmedetomidine and midazolam group had a lower baseline mean heart rate. Systolic and diastolic blood pressure responses measured at preoxygenation, fiberoscope insertion and endotracheal tube placement were not significantly different for both patient groups. The five-point fibreoptic intubation scores showed better patient tolerance in the dexmedetomidine and midazolam group of patients and better comfort score as compared with propofol, and patients were calmer in the dexmedetomidine group.

An innovative technique for nasotracheal fiberoptic intubation using SNPA and its comparison with conventional technique: RCT.

Awake nasotracheal fiberoptic intubation by conventional technique is time consuming and requires expertise. Complications encountered in the conventional technique sometime leads to procedure failure. The primary aim of this study was to compare the innovative technique using split nasopharyngeal airway (SNPA) with the conventional technique for nasotracheal fiberoptic intubation in terms of time taken for intubation. This was a prospective, randomized, and single blind study conducted with 80 patients who were scheduled for maxillofacial surgery. Patients were randomized into two groups, group CFBI (conventional fiberoptic intubation) and group SNPA (split nasopharyngeal airway). In both the groups patients were prepared for awake fiberoptic naso-tracheal intubation. In Group CFBI (N = 41) awake naso-tracheal intubation was achieved by conventional technique of bronchoscope first approach. In Group SNPA (N = 39) spirally split nasopharyngeal airway was used first as a conduit for the passage of fiberoptic bronchoscope. The primary objective was to assess the time taken for intubation. The secondary objectives were to assess the rate of complications in the form of bleeding, cough, desaturation during the procedure, laryngospasm, and nasal bleeding. The time taken for intubation was 6.15 ± 3.0 minutes in CFBI group and 3.10 ± 1.35 minutes in SNPA group and this this difference was statically significant with P value <0.001. Desaturation during the procedure was more in CFBI (99.46 ± 0.75) compared to SNPA (99 ± 0) group with significant difference P value <0.001. Split nasopharyngeal airway was used as conduit for the passage for the flexible fibreoptic bronchoscope and it considerably reduced the time required for fiberoptic nasotracheal intubation compared to the conventional technique of endotracheal tube first approach. Split nasopharyngeal airway provided better intubating conditions with lesser complications and superior patient comfort.

Comparison of intravenous dexmedetomidine alone versus dexmedetomidine ketamine combination on sedation intubation response safety profile and patient satisfaction during awake fiberoptic nasotracheal intubation

Awake fiberoptic intubation requires adequate airway anaesthesia along with good sedation to achieve patient cooperation during intubation without respiratory depression and hypoxia.The purpose of this study was to compare dexmedetomidine alone and dexmedetomidine with ketamine in order to achieve an ideal regimen during awake fiberoptic intubation by providing sedation, good intubating conditions, better hemodynamic stability, and patient satisfaction.This prospective, randomised, double-blind clinical trial included 60 patients who were scheduled for elective surgery under general anaesthetic and required nasotracheal intubation. Patients were randomly assigned to two groups of 30 each, with ages ranging from 18 to 65 years and ASA grades I and II. All patients received an inj. dexmedetomidine bolus at 1 mcg/kg over 10 min. followed by a study drug depending on the group. In Group A, patients will receive an inj. ketamine 15 mg bolus and a 20 mg/hr ketamine infusion, whereas those in Group B will receive a normal saline bolus and infusion till completion of intubation. Sedation by Ramsay sedation scale (RSS), intubation response (by coughing score and grimace score), hemodynamic stability was observed during awake fiberoptic intubation, and patients' satisfaction by visual analogue score (VAS) and recall of events were assessed post operatively at 24 hours. In Group A with greater hemodynamic stability compared to Group B, RSS and Post-Operative Vas Score were more successfully attained. A combination of dexmedetomidine and ketamine provides the optimum sedation, hemodynamic stability, and patient satisfaction during awake fiberoptic intubation.

A Comparative Study between Local Dexmedetomidine and Intravenous Dexmedetomidine during Awake Fiberoptic Nasotracheal Intubation.

Awake fiberoptic intubation (AFOI) is the gold standard for managing a difficult airway. To make the patient comfortable and cooperative during the procedure, many drugs such as benzodiazepines, opioids, or dexmedetomidine are used. Most of these intravenously given drugs may cause respiratory depression and hypoxia. We compared the efficacy of dexmedetomidine through nebulization and transtracheal route with intravenous routes with the primary aim of comparing patient tolerance score (PTS) and secondary objectives of comparing sedation score, cough score, and total duration required for awake fiberoptic nasotracheal intubation. This study was a prospective randomized double-blind study. Seventy-six patients, scheduled for elective surgery requiring AFOI between 18 and 75 years, were included in the study. They were randomly divided into two groups of 38 each. Group I patients received intravenous dexmedetomidine 1 μg.kg-1 and Group L patients received local dexmedetomidine through nebulization 0.5 μg.kg-1 and transtracheal injection 0.5 μg.kg-1. Statistical Package for the Social Sciences version 22 was used. Patients who received dexmedetomidine through nebulization and transtracheal route have significantly better PTSs and less cough scores as compared to patients who received dexmedetomidine by intravenous route (P < 0.05). Hemodynamic parameters and sedation scores between the two groups were statistically insignificant (P > 0.05). The time required for the procedure was significantly less in Group L compared to Group I (P < 0.05). Dexmedetomidine by nebulization and transtracheal route provides optimal conditions for AFOI with good patient tolerance and less cough score as compared to the intravenous route.

Role of endotracheal tube size on nasal and laryngeal morbidity during awake fiberoptic nasotracheal intubation: A Randomized controlled trial.

Background and Aims:Awake fibreoptic nasotracheal intubation is associated with adverse airway and hemodynamic complications. The aim of this study was to evaluate the role of endotracheal tube size on nasal and laryngeal morbidity during awake fibreoptic-guided nasotracheal intubation.Material and Methods:Eighty patients recruited to undergo awake fibreoptic intubation were randomly allocated to Group C (standard size endotracheal tube) and Group S (small size endotracheal tube followed by exchange to standard size using Airway Exchange Catheter under general anesthesia). Nasal morbidity was assessed by incidence of epistaxis, olfactory acuity, and mucociliary clearance. Patient discomfort during intubation was assessed using grimace score and hemodynamic parameters were recorded. Postoperatively, the incidence of nasal and laryngeal injury was recorded using nasendoscopy and telelaryngoscopy, respectively.Results:Demographic profile between the two groups was comparable. Epistaxis was noted in 47.5% of patients in group C as compared to 12.5% in group S. Postoperative olfactory acuity was decreased [2 (1-4) vs 4 (2-5)] and saccharin clearance time was prolonged (314 s vs 134 s) in Group C as compared to Group S. (P-value <0.001) Higher grimace score [2 (1-3) vs 1 (0-2)] and increased hemodynamic response was demonstrated in Group C. (P-value <0.001) Incidence of nasal injury [2 (1-4) vs 1 (0-2)] and laryngeal injury [1 (0-2) vs 0 (0-2)] was more in Group C as compared to Group S.Conclusion:Awake fibreoptic nasotracheal intubation with small size endotracheal tube followed by exchange to standard size under general anesthesia reduces nasal, laryngeal, and hemodynamic complications.

Comparison between lignocaine nebulization and airway nerve blocks for awake fiberoptic nasotracheal intubation in oral cancer surgery patients: Running title: Airway management in oral cancer patients

Intro duction: Awake fiberoptic bronchoscope-guided intubation is the preferred airway management strategy in a patient with a difficult airway and limited mouth opening. The aim is to compare the efficacy of nebulization and airway nerve block using lignocaine to provide airway anesthesia in awake patients using fiberoptic bronchoscope for nasal intubation to make the patient comfortable, cooperative, and agreeable. Methods: In this randomized, prospective, single-blinded study, sixty adult patients scheduled for oral cancer surgeries were divided into two equal groups. Nebulization with 4% lignocaine (10 ml) was performed in Group N, and superior bilateral laryngeal and trans-laryngeal recurrent laryngeal nerve blocks used 2% lignocaine (2 ml) were given in Group B. Nasotracheal intubation using fiberoptic bronchoscope were performed. Intravenous midazolam and fentanyl were used for sedation and analgesia. We recorded the ease of intubation, coughing episodes, vocal cord status, hemodynamic variables, patient recall, and lignocaine toxicity. Student's t-test and Chi-square tests were used for appropriate data. Statistical significance was considered for P &lt; 0.05 (SPSS Version 20, IBM, USA). Results: The intubation time was shorter with better intubating conditions in Group B (120.3 ± 42.6 s) than Group N (200.4 ± 60.3 s) (P &lt; 0.001). Cough severity and patient recall for untoward effects were lower in Group B. Intubation were done successfully in all patients. Conclusion: Airway nerve blocks provided better airway anesthesia characterized by easier fiberoptic intubation and patient comfort than lignocaine nebulization. Nebulization can be considered a suitable alternative when nerve blocks are not feasible due to distorted neck anatomy.

Optimal level of bispectral index for conscious sedation in awake fiberoptic nasotracheal intubation

BackgroundBispectral index (BIS) has been in practice as an objective tool to measure the depth of conscious sedation. The data on adequate levels for awake fiberoptic nasotracheal intubation (AFNI) is however scarce. We aimed to obtain an optimal level of BIS required for achieving the adequate conscious sedation in AFNI procedure. MethodsIn a prospective, observational, outcome assessor blinded cohort trial, 94 consecutive patients with anticipated difficult intubation and undergoing AFNI for any elective surgery were enrolled. The topical anesthesia and sedation were induced with lidocaine and dexmedetomidine, while keeping the patient awake. The sedation levels were targeted to BIS ≤90 and Ramsay sedation score (RSS)≥2 to attempt intubation. Propofol bolus were administered if patients get agitated. The primary outcome was “Stable BIS”, the lowest BIS at which intubation could be feasibly performed. A receiver operator characteristic curve, Youden index, and correlation analysis were used. ResultsThe optimal criterion for BIS was obtained as ≤86 (AUC: 0.80, sensitivity 88.30%, specificity 61.45%, Youden index 49.74). The stable BIS ranged from 80 to 88, while RSS varied from 1 to 3. The BIS and RSS correlated significantly (r: 0.83). The stable BIS was independent of any baseline characteristics. Six patients had transient untoward events, none requiring any intervention. ConclusionBIS serves as an effective objective tool for titrating the depth of conscious sedation. We advocate a BIS range of 80–86 for feasibly performing the AFNI procedure.

Successful Airway and Anesthesia Management Using a High-Flow Nasal Cannula in a Fibrodysplasia Ossificans Progressiva Patient During General Anesthesia: A Case Report

Fibrodysplasia ossificans progressiva (FOP) is a rare hereditary disorder causing neck stiffness, ankylosis of temporomandibular joints, and severe restrictive respiratory dysfunction due to progressive heterotopic ossification of the connective tissue. Herein, we report a case of successful airway and anesthesia management using a high-flow nasal cannula (HFNC) in a 51-year-old man with FOP undergoing partial bone resection of the right greater trochanter of the femur. Although general anesthesia with awake fiberoptic nasotracheal intubation has been described as the gold standard, HFNC may yield another potentially viable option for patients undergoing a surgical procedure that does not involve the airway.

Effect of 4% nebulized lignocaine versus 2% nebulized lignocaine for awake fibroscopic nasotracheal intubation in maxillofacial surgeries.

Introduction:Securing a difficult airway during maxillofacial surgeries is a great challenge for anesthetists, and the flexible fiber-optic bronchoscope is the gold standard while managing such cases. While passing the flexible bronchoscope by the nasal route, the success rate is higher as compared with oral approach as the nasopharynx is in line with the larynx and prevents acute angulation in the oropharynx.Materials and Methods:A randomized control trial was planned in 73 patients out of whom sixty patients gave consent for the procedure. The patients we randomly divided into two groups (n = 30) with application of 4% nebulized lignocaine in one group and the use of 2% nebulized lignocaine in the other group, and the patient's comfort was noted using five-point Puchner scale.Results:The mean value of patient comfort Puchner scale of Group A was 1.30 ± 0.08 and of Group B was 2.23 ± 0.12. The mean value of Puchner scale of Group B was significantly higher (41.8%) as compared to Group A (t = 6.208; df = 51; P < 0.0001). The secondary outcome measures were optimal intubating conditions and hemodynamic changes during awake fiber-optic nasotracheal intubation. The procedural time of two groups when compared showed that the mean procedural time of Group A was shorter (29.67 ± 5.40 min) than the time consumed in Group B (34.93 ± 5.52 min).Conclusion:Four percent nebulized lidocaine provided adequate airway anesthesia and optimal intubating conditions along with stable hemodynamics for awake fiber-optic intubation as compared to 2% nebulized lidocaine.

Magnesium Sulfate and Fentanyl for Facilitating Awake Fiberoptic Nasotracheal Intubation: A Randomized Study

Background: Various drugs have been used to facilitate awake fiberoptic intubation (AFOI). Although fentanyl is probably used most frequently, magnesium sulfate can provide muscle relaxation without respiratory depression and attenuate hemodynamic responses. Methods: We randomly allocated 20 patients of both sexes, aged 18 - 60 years, and ASA status I-II to receive fentanyl 2 μg/kg (group F) or magnesium sulfate 45 mg/kg (group M) before AFOI. The intubating conditions were evaluated by Ramsay sedation score (RSS), cough score, post-intubation score, additional topicalization requirement, and hemodynamic response. Oxygen desaturation, airway morbidity, recall of procedure, and the patient’s willingness to return for the same kind of anesthesia, if required, were also studied. Statistical analyses were done using SPSS V. 17.0 software. Numerical data were analyzed using independent and paired t-tests and categorical data using the chi-square test. P values of < 0.05 were considered significant. Results: RSS, cough score, post-intubation score, lignocaine dose, airway-related morbidity, and willingness to undergo the same kind of anesthesia for a second time were comparable between the two groups. Both drugs had comparable effects on hemodynamic response to intubation. However, the incidence of recall of the procedure was significantly lower in group F (P = 0.003). Conclusions: The degree of coughing during fiberoptic bronchoscopy, tolerance of the endotracheal tube after intubation, and the hemodynamic response to intubation were similar after the administration of either fentanyl 2 μg/kg or magnesium sulfate 45 mg/kg.

Clinical Comparative Study Between Dexmedetomidine, Magnesium sulphate and Ketofol versus Midazolam for Sedation During Awake Fiberoptic Nasotracheal Intubation in Predicted Difficult Air ways Patients

Background and objectives: Awake fiber optic intubation (AFOI) is recommended technique in securing the airway in predicted difficult airway patients with sedation. However, it is not easy to achieve a comfortable sedation so conscious sedation is the key for a successful AFOI. The goal of the study to compare different conscious sedation strategies aimed to improve comfort and safety in patients prepared for elective surgeries. Subjects and Methods: Case control, randomized controlled study in predicted difficult airway patients scheduled for elective surgery under GA carried out at AL-Azhar University Hospitals after approval by the local ethical committee. 120 patients of age group 18-60 years old with ASA I and II prepared for nasal (AFOI) under conscious sedation after giving their informed written consent to participate in our study. The patients were randomly assigned into 4 groups: Group dexmedetomidine (DEX), group ketofol, group magnesium sulfate and group midazolam. HR, MAP, Oxygen saturation and end tidal CO2 were monitored. Sedation score, patient tolerance, patient satisfaction and intubation score (vocal cord movement and coughing) were assessed. Results: All patients were successfully intubated by fiber optic and none of them developed bradycardia or reduced MAP more than 20% from the base line during intubation. Group DEX mild decrease in MAP and HR ( 0.05). Group ketofol and midazolam patients were sedated deeper after the start of the study drugs than group DEX and none of the patients were sedated to a score of < 2 (modified OAA/S score) in either of the groups. Group magnesium showed lighter sedation level significantly different with other groups. Conclusion: Study showed DEX provides optimum sedation without compromising airway or hemodynamic stability with favorable intubation time and less intubation attempts during AFOI in comparison to magnesium sulphate, ketofol and midazolam patients with better patient tolerance and satisfaction.

Clinical Comparative Study Between Dexmedetomidine, Magnesium sulphate and Ketofol versus Midazolam for Sedation During Awake Fiberoptic Nasotracheal Intubation in Predicted Difficult Air ways Patients

Background and objectives: Awake fiber optic intubation (AFOI) is recommended technique in securing the airway in predicted difficult airway patients with sedation. However, it is not easy to achieve a comfortable sedation so conscious sedation is the key for a successful AFOI. The goal of the study to compare different conscious sedation strategies aimed to improve comfort and safety in patients prepared for elective surgeries. Subjects and Methods: Case control, randomized controlled study in predicted difficult airway patients scheduled for elective surgery under GA carried out at AL-Azhar University Hospitals after approval by the local ethical committee. 120 patients of age group 18-60 years old with ASA I and II prepared for nasal (AFOI) under conscious sedation after giving their informed written consent to participate in our study. The patients were randomly assigned into 4 groups: Group dexmedetomidine (DEX), group ketofol, group magnesium sulfate and group midazolam. HR, MAP, Oxygen saturation and end tidal CO2 were monitored. Sedation score, patient tolerance, patient satisfaction and intubation score (vocal cord movement and coughing) were assessed. Results: All patients were successfully intubated by fiber optic and none of them developed bradycardia or reduced MAP more than 20% from the base line during intubation. Group DEX mild decrease in MAP and HR ( 0.05). Group ketofol and midazolam patients were sedated deeper after the start of the study drugs than group DEX and none of the patients were sedated to a score of < 2 (modified OAA/S score) in either of the groups. Group magnesium showed lighter sedation level significantly different with other groups. Conclusion: Study showed DEX provides optimum sedation without compromising airway or hemodynamic stability with favorable intubation time and less intubation attempts during AFOI in comparison to magnesium sulphate, ketofol and midazolam patients with better patient tolerance and satisfaction.

Awake Fiberoptic Nasotracheal Intubation of a Patient with Ankylosing Spondylitis Expected Difficult Intubation

Ankilozan spondilitte omurga kemiklerinin fuzyonu ile sirt ve boyunda esneklik kaybi gelisir. Hastaligin ileri evrelerinde servikal, torakal ve lumbal vertebralarin ankilozu nedeniyle havayolu yonetiminde zorluklarla karsilasilabilir. Bu sunumda, solunum sikintisi nedeniyle acil trakeostomi gerektiren ve agiz acikligi ile boyun hareketlerinin ileri derecede kisitli olusu nedeniyle zor havayolu beklenen ankilozan spondilitli bir hastaya uyanikken uygulanan fiberoptik nazotrakeal entubasyon anlatilmistir.

Awake fiberoptic nasotracheal intubation for patients with difficult airway

Awake fiberoptic nasotracheal intubation is a useful technique, especially in patients with airway obstruction. It must not only provide sufficient anesthesia, but also maintain spontaneous breathing. We introduce a method to achieve this using a small dose of fentanyl and midazolam in combination with topical anesthesia. The cases of 2 patients (1 male, 1 female) who underwent oral maxillofacial surgery are reported. They received 50 µg of fentanyl 2–3 times (total 2.2–2.3 µg/kg) at intervals of approximately 2 min. Oxygen was administered via a mask at 6 L/min, and 0.5 mg of midazolam was administered 1–4 times (total 0.02–0.05 mg/kg) at intervals of approximately 2 min. A tracheal tube was inserted through the nasal cavity after topical anesthesia was applied to the epiglottis, vocal cords, and into the trachea through the fiberscope channel. All patients were successfully intubated. This is a useful and safe method for awake fiberoptic nasotracheal intubation.

Nebulisation Versus Spray-as-You-Go Airway Topical Anaesthesia in Patients with Temporomandibular Joint Ankylosis using 2% Lignocaine.

This randomized, comparative clinical study was designed to compare 2% lignocaine nebulization and 2% lignocaine via spray-as-you-go technique for topical airway anaesthesia during or awake flexible fiberoptic intubation (AFOI) in temporomandibular joint (TMJ) ankylosis patients. Sixty adult patients with TMJ ankylosis were randomly assigned to the following study groups using a computer generated random number table2% lignocaine nebulised (group A) and 2% lignocaine via spray-as-you-go technique (group B). After airway anaesthesia, awake flexible fiberoptic nasotracheal intubation was performed. An independent investigator who did not participate in the study scored patients' comfort during airway topical anaesthesia and patients' reaction during awake FOI. Changes in haemodynamics during the airway manipulation were also observed. There were no statistically significant differences in the observed variables between the two groups. Both 2% lignocaine nebulization and 2% lignocaine spray-as-you-go technique provided acceptable conditions for AFOI in TMJ patients.

A comparison of dexmedetomidine plus ketamine combination with dexmedetomidine alone for awake fiberoptic nasotracheal intubation: A randomized controlled study.

Background and Aims:We designed a study to compare the effectiveness of dexmedetomidine plus ketamine combination with dexmedetomidine alone in search of an ideal sedation regime, which would achieve better intubating conditions, hemodynamic stability, and sedation for awake fiberoptic nasotracheal intubation.Materials and Methods:A total of 60 adult patients of age group 18-60 years with American Society of Anesthesiologists I and II posted for elective surgery under general anesthesia were randomly divided into two groups of 30 each in this prospective randomized controlled double-blinded study. Groups I and II patients received a bolus dose of dexmedetomidine at 1 mcg/kg over 10 min followed by a continuous infusion of dexmedetomidine at 0.5 mcg/kg/h. Upon completion of the dexmedetomidine bolus, Group I patients received 15 mg of ketamine and an infusion of ketamine at 20 mg/h followed by awake fiberoptic nasotracheal intubation, while Group II patients upon completion of dexmedetomidine bolus received plain normal saline instead of ketamine. Hemodynamic variables like heart rate (HR) and mean arterial pressure (MAP), oxygen saturation, electrocardiogram changes, sedation score (modified Observer assessment of alertness/sedation score), intubation score (vocal cord movement and coughing), grimace score, time taken for intubation, amount of lignocaine used were noted during the course of study. Patient satisfaction score and level of recall were assessed during the postoperative visit the next day.Results:Group I patients maintained a stable HR and MAP (<10% fall when compared with the baseline value). Sedation score (3.47 vs. 3.93) and patient satisfaction score were better in Group I patients. There was no significant difference in intubation scores, grimace scores, oxygen saturation and level of recall when compared between the two groups (P > 0.05).Conclusion:The use of dexmedetomidine plus ketamine combination in awake fiberoptic nasotracheal intubation provided better hemodynamic stability and sedation than dexmedetomidine alone.

Dexmedetomidine versus remifentanil sedation during awake fiberoptic nasotracheal intubation: a double-blinded randomized controlled trial

Awake fiberoptic nasotracheal intubation is usually performed in patients with an anticipated difficult airway. This study compares dexmedetomidine and remifentanil for conscious sedation during fiberoptic intubation. Forty patients undergoing elective awake fiberoptic nasotracheal intubation were allocated randomly to receive either dexmedetomidine (n=20) or remifentanil (n=20). Primary outcome measures were endoscopy, intubation, and post-intubation conditions as scored by the attending anesthesiologist. Other parameters included the time taken to achieve the desired level of sedation, endoscopy time, intubation time, and hemodynamic changes during the procedure. An interview was conducted 24h after surgery to evaluate patients' recall of and satisfaction with the procedure. The median [interquartile range] endoscopy score (graded 0-5) in the dexmedetomidine group (2 [1-2]) was significantly better than in patients who received remifentanil (3 [2-3]; p<0.01). Recall of intubation was significantly lower in the dexmedetomidine group (p=0.027). Dexmedetomidine provided better patient satisfaction than remifentanil (2 [1-2] and 2 [2-3], respectively; p=0.022). Patients in the dexmedetomidine group had fewer heart rate responses during endoscopy and intubation as compared to the remifentanil group (p<0.001 and p=0.004, respectively). Peripheral oxygen saturation was less in the remifentanil group during endoscopy (p=0.003). There were no significant differences in intubation and post-intubation conditions. Both dexmedetomidine and remifentanil were effective as sedatives in patients undergoing awake fiberoptic nasotracheal intubation. Compared with remifentanil, dexmedetomidine offered better endoscopy scores, lower recall of intubation, and greater patient satisfaction, with minor hemodynamic side effects.

Use of the Airtraq® optical laryngoscope as a rescue airway device following failed awake flexible fiberoptic nasotracheal intubation of a patient with severe microsomia - A case report -

We report here the successful use of the AirtraqⓇ optical laryngoscope (AOL) as a rescue device following failed awake flexible fiberoptic nasotracheal intubation of a patient with severe mandibular microsomia. We attempted awake fiberoptic nasotracheal intubation following topical anesthesia with 4% lidocaine spray three times to induce general anesthesia for distraction osteogenesis of mandibular bone. However, due to a shallow pharyngeal cavity and cranially displaced larynx, we failed to locate the larynx each time and were therefore not able to intubate the patient. Awake orotracheal intubation using the AOL allowed us to easily intubate the patient. Therefore, we recommend that the AOL be used as a rescue airway device for intubation of difficult airways.