Awake Fiberoptic Orotracheal Intubation Research Articles

A Randomized Controlled Trial: Examining the Impact of the Novel Double Setup Endotracheal Tube on the Success Rates of Awake Fiber-Optic Orotracheal Intubation

Background: Advancing the endotracheal tube (ETT) over a flexible bronchoscope (FB) during awake fiber-optic intubation (AFOI) is often impeded. Various maneuvers and tracheal tubes designed to overcome this obstruction may also be unsuccessful or costly. Objective: The current study aimed to assess how the novel double configuration ETT affected AFOI success rates on the first attempt. Methods: A randomized controlled experiment including 40 individuals receiving awake fiber-optic orotracheal intubation was performed in a 1:1 ratio with a single ETT railroaded with its bevel posteriorly (ST) or railroading with a double setup ETT (DT) over a flexible videoscope (FVS) for tracheal intubation. The number of intubation attempts, time spent intubating, and adverse events were examined and compared between the two groups. Results: Twenty patients received a single ETT railroaded with the bevel posteriorly, and 20 patients received railroading with the double setup ETT during AFOI. Intubation on the first attempt was significantly greater in the DT group (90%) than in the ST group (35%). The intubation time was considerably shorter for the DT group (12.8 [7.8–16.9] s) when compared with the ST group (27.9 [16.3–91.0] s). Five patients were intubated by the alternative technique after failure to intubate for several attempts, and 3 cases were found to have a crease in the FVS after intubation in group ST. During topical anesthetic, three individuals in each group experienced transient oxygen desaturation. Conclusions: Our study discovered that the novel double setup tube could significantly improve the intubation success rate on the first attempt during AFOI for patients with challenging airway when a strategy based on a reduced gap between ETT and FB could not be applied.

A comparative evaluation of dexmedetomidine and magnesium sulfate during awake fiber optic orotracheal intubation in patients scheduled for cervical spine surgeries: A prospective study

Background: Fiber optic intubation has become an integral part in management of anticipated difficult airways. Various anesthetic drugs have been used to assist awake fiber optic intubation (AFOI) for producing conscious sedation to provide a calm, cooperative, and responsive patient without respiratory depression for successful awake fibre optic intubation. Aims and Objectives: The aim of the present study was to compare the efficacy of dexmedetomidine and magnesium sulfate during awake fiber optic orotracheal intubation in patients scheduled for cervical spine surgeries. Materials and Methods: A randomized, prospective, and comparative study design was conducted in 60 patients in JAH group of hospitals. All patients were randomly divided into two groups: Group A (n=30) patients received dexmedetomidine (1 μg/kg) and Group B (n=30) patients received magnesium sulfate (40 mg/kg) in 100 ml normal saline over 10 min. The fiber optic orotracheal intubation was performed and primary outcome was level of sedation assessed using Ramsay sedation score. Other parameters of study included cough score and intubation score to compare intubating conditions. The secondary outcomes of study included variations in hemodynamic parameters heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and SPO2 during drug infusion at 2-min interval, immediately after intubation and every 10 min after intubation till 30 min. Results: Group A (Dexmedetomidine) had better sedation score, cough score, and intubation score with stable hemodynamic variables than Group B (Magnesium Sulphate) with statistically significant results. Conclusion: Patients receiving dexmedetomidine had better sedation providing more optimum conditions for AFOI with stable hemodynamic parameters and lesser adverse effects during the procedure than magnesium sulfate.

Awake fiberoptic orotracheal intubation using a modified Guedel airway in a patient with craniocervical instability and an anticipated difficult airway - A case report -

In patients with upper cervical instability, airway management may provoke subluxation of the craniocervical region and neurologic injury, and can be challenging for the anesthesiologist. Endotracheal intubation using a fiberoptic bronchoscope is frequently used in these patients to minimize spine motion, but this procedure may fail in patients with altered airway anatomy. When fiberoptic endotracheal intubation fails in these patients, optional intubation methods are limited. We describe successful awake fiberoptic orotracheal intubation using a modified Guedel airway divided in the midline for a 59-year-old man with an anticipated difficult airway, due to limited mouth opening, a nasopharyngeal tumor, and craniocervical spine instability after failure of conventional fiberoptic orotracheal intubation. Keywords: Airway; Bronchoscope; Guedel airway; Instability; Neck

RETRACTED: Proficiency of Dams Tulip-i® in awake fiberoptic orotracheal intubation for difficult airway

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief as it contains fabricated/falsified data. The Editor-in-Chief decision was based on the investigation by the Japanese Society of Anesthesiologists which concluded that no research was conducted and all the data including patient backgrounds were fabricated. The society also concluded that the corresponding author, Dr. Ueshima presented the names of the individuals not involved or only partially involved in research as lead authors, presented the names of the individuals not involved in research as co-authors and submitted papers without the agreement of the co-authors. The investigation report can be found here.

Comparison between remifentanil and dexmedetomidine for sedation during modified awake fiberoptic intubation.

Cricothyroid membrane injections and the application of a coarse fiberoptic bronchoscope (FOB) below the vocal cords for topical anesthesia have a number of limitations for certain patients. Thus, the aim of the present observational study was to assess the effect of a novel modified topical anesthesia method using the effective sedation drugs, remifentanil (Rem) or dexmedetomidine (Dex), during awake fiberoptic orotracheal intubation (AFOI). In total, 90 adult patients, who had been classified as American Society of Anesthesiologists I–II, were included in the study. The patients had anticipated difficult airways and were to undergo orotracheal intubation for elective surgery. The patients were enrolled in the double-blinded randomized pilot study and received Rem or Dex for sedation during the modified AFOI procedure. The two groups received 2% lidocaine for topical anesthesia via an epidural catheter, which was threaded through the suction channel of the FOB. The main clinical outcomes were evaluated by graded scores representing the conditions for intubation and post-intubation. Additional parameters analyzed included airway obstruction, hemodynamic changes, time required for intubation, amnesia level and subjective satisfaction. All 90 patients were successfully intubated using the modified AFOI technique. The comfort scores and airway events during intubation did not significantly differ between the two groups. However, the Rem group experienced less coughing, and less time was required for tracheal intubation when compared with the Dex group. No statistically significant differences were observed in the changes to the mean arterial pressure and heart rate at any time point between the two groups. Therefore, the current study demonstrated that the modified AFOI method is feasible and effective for difficult airway management, and that Dex and Rem exhibit similar efficacy as adjuvant therapies.

Use of a Modified Ovassapian Airway to Increase Mouth Opening for Fiberoptic Orotracheal Intubation in a Patient with Severe Trismus

To the Editor When the outside diameter of the endotracheal tube is greater than the interincisor distance, oral intubation between the teeth is impossible. We present a novel approach to increase the oral aperture in a patient with severe trismus. A modified Ovassapian airway was used as a wedge to increase mouth opening, enabling fiberoptic oral intubation. Written patient consent was obtained for this submission. A 67-year-old man with oral carcinoma presenting for mandibulectomy had undergone prior tumor resection and radiotherapy. Osteoradionecrosis caused marked trismus. Because of the recent placement of a drug-eluting stent for coronary artery disease, aspirin and clopidogrel were continued throughout the perioperative period to prevent stent thrombosis. Nasal tracheal intubation was undesirable because of the risk of epistaxis. His interincisor distance was 8 mm and it was impossible to fully insert an Ovassapian airway into the mouth. The airway was modified by cutting out the proximal ring of the intubating channel. It was then possible to insert the airway deeper into the oral cavity and advance as a slanted wedge, slowly increasing mouth opening to 12 mm (Fig. 1) and allowing successful awake fiberoptic orotracheal intubation. By achieving a modest increase in mouth opening, this modified Ovassapian airway enabled successful oral intubation.Figure 1: Modified airway inserted deeper into the mouth to increase interincisor distance.Angela Truong, MD Dam-Thuy Truong, MD Department of Anesthesiology and Perioperative Medicine University of Texas M.D. Anderson Cancer Center Houston, Texas [email protected]

Awake Glidescope® intubation in a patient with a huge and fixed supraglottic mass -A case report-.

Intubating patients with a huge, fixed supraglottic mass causing an obstruction of the glottis is difficult to most anesthesiologists. We attempted awake fiberoptic orotracheal intubation assisted by Glidescope® Videolaryngoscope (GVL) following topical anesthesia with 4% lidocaine spray and remifentanil infusion. The glottis could not be identified by the GVL view. However, by entering toward the right side of the mass with bronchoscope, the glottis was found. Due to stiffness of the mass, we were unable to further enter the area using the bronchoscope. Alternatively, we attempted to expose the glottis by GVL blade and then successfully intubated the patient by manually pressing the cricoids cartilage. GVL is nonetheless an excellent instrument in airway management compared to fiberoptic bronchoscope for patients with a huge and fixed supraglottic mass.

Spray-As-You-Go Airway Topical Anesthesia in Patients with a Difficult Airway: A Randomized, Double-Blind Comparison of 2% and 4% Lidocaine

We designed this randomized, double-blind clinical study to compare the safety and efficacy of 2% and 4% lidocaine during airway topical anesthesia with a spray-as-you-go technique via the fiberoptic bronchoscope. Fifty-two adult patients with a difficult airway were randomly assigned to 1 of 2 study groups to receive 2% (Group 1) or 4% lidocaine (Group 2) by a spray-as-you-go technique with the fiberoptic bronchoscope, in a double-blind manner. After airway topical anesthesia, awake fiberoptic orotracheal intubation (FOI) was performed. Level of sedation, time for each lidocaine spray in different targeted areas, total times for airway sprays, total dosages of lidocaine used for airway sprays, intubation times, and number of intubation attempts were noted. An independent investigator scored patients' comfort during airway topical anesthesia, patients' reaction, coughing severity, and intubating condition during awake FOI, and observed changes of arterial blood pressure and heart rate during each stage in the airway manipulation process. Serial blood samples were obtained for analysis of plasma lidocaine concentrations. Except for the total dosages and plasma concentrations of lidocaine, there were no significant differences in any of the observed variables between groups. All patients exhibited excellent or acceptable intubating conditions. The total dosages of lidocaine were significantly smaller in Group 1 (3.4 +/- 0.6 mg/kg) than in Group 2 (7.1 +/- 2.1 mg/kg). The plasma lidocaine concentrations in all observed points after the supraglottic sprays were larger in Group 2 than in Group 1. Both 2% and 4% lidocaine administered topically by a spray-as-you-go technique can provide clinically acceptable intubating conditions for awake FOI in sedated patients with a difficult airway. As compared with 4% lidocaine, however, 2% lidocaine requires a smaller dosage and results in lower plasma concentrations.

Optimal effect concentration of remifentanil in awake fiberoptic orotracheal intubation

Anaesthesia and Critical Care, School of Medicine. Universidad de Navarra, Pamplona, Navarra, Spain

Pain Management: Citizenship or Human Right?

1. Johnson DM, From AM, Smith RB, From RP, Maktabi MA. Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation. Anesthesiology 2005;102:910–14 2. Kihara S, Yaguchi Y, Taguchi N, Brimacombe JR, Watanabe S. The Styletscope is a better intubation tool than a conventional stylet during simulated cervical spine immobilization. Can J Anaesth 2005;52:105–10

Effect of orientation of a standard polyvinyl chloride tracheal tube on success rates during awake flexible fibreoptic intubation*

We conducted a randomised study in 70 patients to assess the effect of orientation of a standard polyvinyl chloride tracheal tube on the ease of railroading the tube during awake fiberoptic orotracheal intubation. Conventional orientation of the tube (with the bevel of the tube directed to the patient's left) was compared with orientation of the tube with the bevel facing posteriorly. The success rate of intubation at the first attempt was higher with the bevel oriented posteriorly (35/35; 100%) than with the conventional orientation (21/35; 60%; p = 0.0001), and the intubating time was shorter (median (range) 7 (5-11) s and 11 (5-60) s, respectively; p = 0.0001). We recommend that the tracheal tube should be aligned in this manner when railroading it over the fibrescope during awake fibreoptic orotracheal intubation.

Endoscopic Study of Mechanisms of Failure of Endotracheal Tube Advancement into the Trachea During Awake Fiberoptic Orotracheal Intubation

Endoscopic Study of Mechanisms of Failure of Endotracheal Tube Advancement into the Trachea During Awake Fiberoptic Orotracheal Intubation

Endoscopic Study of Mechanisms of Failure of Endotracheal Tube Advancement Into the Trachea During Awake Fiberoptic Orotracheal Intubation

Endoscopic Study of Mechanisms of Failure of Endotracheal Tube Advancement Into the Trachea During Awake Fiberoptic Orotracheal Intubation

Endoscopic Study of Mechanisms of Failure of Endotracheal Tube Advancement into the Trachea during Awake Fiberoptic Orotracheal Intubation

Advancing the endotracheal tube (ETT) over a flexible bronchoscope (FB) during awake fiberoptic orotracheal intubation is often impeded. The goal of this study was to identify the sites and mechanisms that inhibit the passing of the ETT into the trachea. Forty-five consenting patients underwent a clinically indicated awake fiberoptic orotracheal intubation. After topical anesthesia, nerve block, or both, an awake fiberoptic orotracheal intubation was performed. The placement of the FB and advancement of the ETT over the FB were videotaped using a second nasally inserted FB. An otolaryngologist later reviewed the videotaped data. The right arytenoid or the interarytenoid soft tissues inhibited advancement of the ETT in 42 and 11% of all patients, respectively. In all cases in which the FB was located on the right side of the larynx, failure of ETT advancement almost always occurred at the right arytenoid. Withdrawing the ETT and rotating it 90 degrees counterclockwise resulted in successful intubation on the second, third, and fourth attempts in 26.6, 20, and 0.7% of patients, respectively. The right arytenoid frequently inhibits advancement of the ETT over the FB into the trachea during awake fiberoptic orotracheal intubation. The FB position in the larynx before tube advancement and the orientation of the ETT are relevant factors in failure of advancement of the ETT into the trachea. The authors recommend positioning the FB in the center of the larynx and orienting the bevel of the ETT to face posteriorly during the first attempt at intubation.

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