Awake Fiberoptic Research Articles

Conscious Sedation and Awake Fiberoptic Intubation in a Patient with Difficult Mask Ventilation—A Case Report

Since maxillofacial malignancy is a common cause of facial defects and disfigurement of the face that may make fitting of a mask difficult and cause air leakage from the side, thus making mask ventilation difficult. In addition, distorted anatomy of the airway and base of the skull in such patients may cause difficult intubation (DI). We experienced a case with a huge facial defect due to maxillary carcinoma, in which difficult mask ventilation (DMV) and DI were predicted. After evaluation by three-dimensional airway computed tomography, the airway was secured with conscious sedation using dexmedetomidine, and awake fiberoptic intubation was safely performed. Three-dimensional airway computed tomography seems to be a good tool for successful intubation when DMV and DI are predicted.

Awake Fiberoptic or Awake Laryngoscopic Tracheal Intubation in Patients With Anticipated Difficult Airway Management

Rosenstock, Charlotte V.*; Thøgersen, Bente†; Afshari, Arash‡; Christensen, Anne-Lise*; Eriksen, Claus*; Gätke, Mona M.† Author Information

Awake Fiberoptic Intubation and Self-positioning in Patients at Risk of Secondary Cervical Injury

This study was designed to document the feasibility of self-positioning after awake fiberoptic intubation of the trachea using primarily effective topical anesthesia rather than sedation. We investigated 14 patients (ASA physical status 1 to 3) with a neurosurgical diagnosis of cervical instability or at risk of secondary cervical injury, who were scheduled for awake fiberoptic intubation and self-positioning prone. Topical anesthesia was accomplished using an oropharyngeal spray of lidocaine alone or in combination with a transtracheal injection of lidocaine for awake fiberoptic intubation and self-positioning prone. Patients evidencing anxiolysis were given midazolam 2 to 4 mg, i.v.. We assessed the need for sedation, tolerance of the endotracheal tube, patient comfort, incidence of coughing or gagging, and changes in heart rate, blood pressure, and oxygen saturation. In addition, patients were interviewed on the first postoperative day and asked to categorize the experience of awake intubation and positioning as a positive, neutral, or negative experience, or to have no recall. Eleven of the 14 patients turned themselves prone after awake fiberoptic intubation. No additional sedation was necessary for accomplishing positioning. Whereas 50% of the patients (7/14) showed mostly slight coughing or gagging during fiberoptic intubation, none of the patients who were positioned awake had coughing or gagging during tube fixation and prone positioning. The technique was unsuccessful in 3 patients. None of the patients viewed this as a negative experience. Our study demonstrates that awake fiberoptic intubation and patient self-positioning was feasible in this sample of patients at risk of secondary cervical injury. This technique may extend the opportunity of continuous neurological monitoring in patients with a risk of position-related cervical injury, especially where electrophysiological monitoring is not possible or is unavailable.

Awake Fiberoptic or Awake Video Laryngoscopic Tracheal Intubation in Patients with Anticipated Difficult Airway Management

Awake flexible fiberoptic intubation (FFI) is the gold standard for management of anticipated difficult tracheal intubation. The purpose of this study was to compare awake FFI to awake McGrath® video laryngoscope, (MVL), (Aircraft Medical, Edinburgh, Scotland, United Kingdom) intubation in patients with an anticipated difficult intubation. The authors examined the hypothesis that MVL intubation would be faster than FFI. Ninety-three adult patients with anticipated difficult intubation were randomly allocated to awake FFI or awake MVL, patients were given glycopyrrolate, nasal oxygen, topical lidocaine orally, and a transtracheal injection of 100 mg lidocaine. Remifentanil infusion was administered intravenously to a Ramsay sedation score of 2-4. Time to tracheal intubation was recorded by independent assessors. The authors also recorded intubation success on the first attempt, investigators' evaluation of ease of the technique, and patients reported intubation-discomfort evaluated on a visual analog scale. Eighty-four patients were eligible for analysis. Time to tracheal intubation was median [interquartile range, IQR] 80 s [IQR 58-117] with FFI and 62 s [IQR 55-109] with MVL (P = 0.17). Intubation success on the first attempt was 79% versus 71% for FFI and MVL, respectively. The median visual analog scale score for ease of intubation was 2 (IQR 1-4) versus 1 (IQR 1-6) for FFI and MVL, respectively. The median visual analog scale score for patients' assessment of discomfort for both techniques was 2, FFI (IQR 0-3), MVL (IQR 0-4). The authors found no difference in time to tracheal intubation between awake FFI and awake MVL intubation performed by experienced anesthesiologists in patients with anticipated difficult airway.

Dexmedetomidine versus Remifentanil for Sedation during Awake Fiberoptic Intubation

This study compared remifentanil and dexmedetomidine as awake fiberoptic intubation (AFOI) anesthetics. Thirty-four adult ASA I-III patients were enrolled in a double-blinded randomized pilot study to receive remifentanil (REM) or dexmedetomidine (DEX) for sedation during AFOI (nasal and oral). Thirty patients completed the study and received 2 mg midazolam IV and topical anesthesia. The REM group received a loading dose of 0.75 mcg/kg followed by an infusion of 0.075 mcg/kg/min. The DEX group received a loading dose of 0.4 mcg/kg followed by an infusion of 0.7 mcg/kg/hr. Time to sedation, number of intubation attempts, Ramsay sedation scale (RSS) score, bispectral index (BIS), and memory recall were recorded. All thirty patients were successfully intubated by AFOI (22 oral intubations/8 nasal). First attempt success rate with AFOI was higher in the REM group than the DEX group, 72% and 38% (P = 0.02), respectively. The DEX group took longer to attain RSS of ≥3 and to achieve BIS <80, as compared to the REM group. Postloading dose verbal recall was poorer in the DEX group. Dexmedetomidine seems a useful adjunct for patients undergoing AFOI but is dependent on dosage and time. Further studies in the use of dexmedetomidine for AFOI are warranted.

Dexmedetomidine for Awake Fiberoptic Intubation in a Parturient With Spinal Muscular Atrophy Type III for Cesarean Delivery

Dexmedetomidine for Awake Fiberoptic Intubation in a Parturient With Spinal Muscular Atrophy Type III for Cesarean Delivery

A Phase IIIb, Randomized, Double-blind, Placebo-controlled, Multicenter Study Evaluating the Safety and Efficacy of Dexmedetomidine for Sedation During Awake Fiberoptic Intubation

GABA-mediated sedatives have respiratory depressant properties that may be detrimental in patients with difficult airways. In this randomized, double-blind, multicenter, Phase IIIb Food and Drug Administration study, safety and efficacy of dexmedetomidine compared with placebo were evaluated as the primary sedative for awake fiberoptic intubation (AFOI). Patients were randomized to receive dexmedetomidine or saline. Patients were sedated with dexmedetomidine or rescue midazolam to achieve targeted sedation (Ramsay Sedation Scale ≥ 2) before topicalization and throughout AFOI. Primary efficacy endpoint was percentage of patients requiring rescue midazolam; secondary efficacy endpoints were total dose of rescue midazolam, percentage requiring additional rescue nonmidazolam medications, anesthesiologist's assessment of ease of subject care, and patient recall and satisfaction 24 hours postoperatively. Less rescue midazolam was required to maintain Ramsay Sedation Scale ≥2 (47.3% vs. 86.0%, P < 0.001), and supplemental midazolam dose was lower (1.07 ± 1.5 mg vs. 2.85 ± 3.0 mg, P < 0.001) with dexmedetomidine compared with placebo. More Mallampati Class IV patients treated with dexmedetomidine were successfully intubated without midazolam than with placebo (66.7% vs. 8.3%, P = 0.009). Dexmedetomidine decreased blood pressure and heart rate compared with placebo patients sedated with midazolam. Patients and anesthesiologists showed favorable satisfaction responses in both groups. Adverse events and patient recall were similar in both groups. Dexmedetomidine is effective as the primary sedative in patients undergoing AFOI. Some patients may require small supplemental doses of midazolam, in addition to dexmedetomidine, to achieve sufficient sedation for AFOI. Dexmedetomidine provides another AFOI option for sedation of patients with difficult airways.

First International Congress of Airway Management and Anesthesia in Head and Neck Surgery, Tehran, Iran, May 20–22, 2009

First International Congress of Airway Management and Anesthesia in Head and Neck Surgery, Tehran, Iran, May 20–22, 2009

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

Awake Fiberoptic Intubation Using an Optical Stylet in an Anticipated Difficult Airway

Numerous rigid indirect fiberoptic and video-based airway tools have been developed as potential alternatives to direct laryngoscopy for intubation. Compared with flexible fiberoptic bronchoscopes, these devices are less expensive and may be easier to use. The role of these rigid instruments in managing the difficult airway in the emergency department is yet to be defined. This article details the use of a rigid fiberoptic stylet to manage an anticipated difficult airway by using topical anesthetic without sedation.

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

Lidocaine Toxicity in Volunteer Subjects Undergoing Awake Fiberoptic Intubation

To the Editor: The paper by Martin et al. (1) raises serious concerns. Anesthesiologists acting as subjects on a training course in awake intubation were used to validate a training manikin. Martin et al. failed to set an upper dose limit for topical lidocaine administration and observed side effects indicating lidocaine toxicity. Death as a result of lidocaine toxicity has occurred in a healthy 19-yr-old college student volunteer after bronchoscopy for research purposes (2). That research protocol also failed to specify an upper dose limit for lidocaine. The safety of volunteers and subjects should be paramount. It is essential to specify an upper dose limit when using toxic drugs for research or when providing this type of training on volunteers. Nicholas M. Woodall, MBChB, FRCA Robert J. Harwood, MBBS, FRCA Graham L. Barker, MBBS, FRCA Department of Anaesthesia The Norfolk and Norwich University Hospital Norwich, U.K. [email protected]

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.

Dexmedetomidine and Awake Fiberoptic Intubation for Possible Cervical Spine Myelopathy

For many anesthesiologists, awake fiberoptic endotracheal intubation (AFOBI) is the preferred method of intubation when treating patients with symptoms or signs of cervical spinal cord compression. The advantage of this method is to minimize cervical spine movements that could contribute to neurologic impairment. In patients who are anxious or poorly cooperative, adequate sedation in addition to topicalization of the airway may be key to minimize patient discomfort and assist in successful intubation, but imposes the risk of respiratory depression. Dexmedetomidine has the advantage of producing sedation without a significant decrease in respiratory drive. We are now reporting our experience of a series of AFOBI using dexmedetomidine for sedation. A retrospective chart review was conducted on the anesthetic records of patients, who had undergone an awake fiberoptic endotracheal intubation (AFOBI) using dexmedetomidine for sedation. These were patients in whom AFOBI was indicated because of signs or symptoms of cervical spinal cord compression. Dexmedetomidine provided adequate sedation. We did not encounter any loss of airway or airway obstruction during the intubation. The patients had excellent cooperation for post-intubation neurologic examination. Thirteen patients developed transient hypotension after induction of general anesthesia that was managed with boluses of phenylephrine or ephedrine.

Both Local Anesthetics and Salbutamol Pretreatment Affect Reflex Bronchoconstriction in Volunteers with Asthma Undergoing Awake Fiberoptic Intubation

Survey of Anesthesiology: February 2004 - Volume 48 - Issue 1 - p 36 doi: 10.1097/01.sa.0000108455.59995.9c

Laryngeal Trauma During Awake Fiberoptic Intubation

Laryngeal Trauma During Awake Fiberoptic Intubation

Airway Regional Anesthesia for Awake Fiberoptic Intubation

Airway Regional Anesthesia for Awake Fiberoptic Intubation

The Intubating Laryngeal Mask Airway After Induction of General Anesthesia Versus Awake Fiberoptic Intubation in Patients with Difficult Airways

We performed the current study to compare tracheal intubation (TI) using awake fiberoptic intubation (AFOI) and TI using the intubating laryngeal mask airway (ILMA) in patients with difficult airway. Our hypothesis was that patients with difficult airways could be safely intubated after induction of anesthesia using the ILMA. After ethics approval and informed consent, 38 patients who were identified to have difficult airways were randomly assigned to AFOI or TI using the ILMA. Patients in the AFOI group had the usual sedation and airway topicalization. Patients in the ILMA group were induced with propofol for ILMA insertion and succinylcholine for TI. The first TI attempt was done blindly via the ILMA and all subsequent attempts were performed with fiberoptic guidance. All patients in the ILMA group were successfully ventilated. Successful TI was achieved in all patients in both groups. However, in 10% of the patients in the ILMA group, TI was achieved by a second anesthesiologist who was more experienced with the use of the ILMA. In a postoperative questionnaire, patients in the ILMA group were more satisfied with their method of TI (P < 0.01). The ILMA is a useful device in the management of patients with difficult airways and may be a valuable alternative to AFOI when AFOI is contraindicated or in the patient with the unanticipated difficult airway. The intubating laryngeal mask airway is a useful device in the management of patients with difficult airways and may be a valuable alternative to awake fiberoptic intubation (AFOI) when AFOI is contraindicated or in the patient with the unanticipated difficult airway.

New Jaw Support Device and Awake Fiberoptic Intubation

To the Editor: The jaw support device (JSD), designed to support the bilateral angle of the patient’s jaw, facilitates exposure of the larynx and maintenance of airway patency without the need for an assistant during fiberoptic intubation in anesthetized, paralyzed patients (1). The first prototype of this device, however, can be used only with the Maquet Operating Table System (MAQUET, Rastatt, Germany) and requires the manipulation of six screws (three on each side) for adjustment. To overcome these problems, we have developed a new prototype of the JSD (Arizono Orthopedic Supplies Company Ltd., Kitakyushu, Japan). This new device is attached to a stainless board, which enables it to be used on any operating table, and it is easily and quickly adjustable to fit the jaw by using the easy locking mechanism and levers (Figure 1).Figure 1: A new jaw support device supporting the bilateral angle of the jaw. The device maintains jaw thrust and head extension. Bilateral heads (A) attached to the easy-locking poles are adjustable to the desired height and direction by simply pulling up. Bilateral universal arms (B) attached to a stainless board can be fixed only by pushing the levers (C). The device may be additionally secured in place by using two screws (white arrow) on each side. The head is covered with a soft cushion that can support the angle of the jaw without discomfort, even in a conscious patient.The JSD has been used for fiberoptic intubation under general anesthesia, but it is also useful for conscious fiberoptic intubation. During fiberoptic intubation in patients with conscious sedation or deep sedation, a jaw thrust maneuver by an assistant is sometimes required (2) because pharyngeal and laryngeal structures tend to move posteriorly, which can obstruct the airway and fiberoptic view. In these sedated patients, the JSD facilitates laryngeal exposure and maintenance of airway patency without the need for an assistant. This device can be used without discomfort for conscious patients, but it should be used for a short duration to minimize the potential risk of local skin or nerve damage. We have used this device in several sedated patients who required awake fiberoptic intubation and found that it was valuable. Kazuyoshi Aoyama MD* Etsuko Nagaoka MD* Ichiro Takenaka MD† Tatsuo Kadoya MD†

The efficacy and safety of EMLA cream for awake fiberoptic endotracheal intubation.

EMLA Cream (EC; Astra, Westborough, MA) has been widely used as a local anesthetic. Limited safety information is available with respect to the application of EC to the oral mucous membranes. The purpose of this pilot study was to evaluate the efficacy and safety of EC when applied to oral mucosa for fiberoptic intubation. Twenty ASA physical status I-IV patients (11 women and 9 men), 28-57 yr old, who were scheduled for awake, fiberoptic, intubation participated in this open-label study. A total of 4 g of EC was used for 5 min until the patient showed no evidence of a gag reflex (this was evaluated clinically by the patient's acceptance of the William's airway and considered the endpoint for assessing adequate topicalization of the oropharynx). The measured peak plasma concentration of lidocaine or prilocaine did not reach toxic levels in any patient. Methemoglobin levels did not exceed normal values (1.5%) in any patient, and there was no relationship between methemoglobin levels and patient weight, amount of EC used, measured peak plasma concentration, or times to measured peak concentrations of prilocaine or lidocaine. We conclude that EC provided satisfactory topical anesthesia allowing for successful oral fiberoptic intubation in all patients and should be considered a safe alternative for anesthetizing the airway of patients requiring awake oral fiberoptic intubation.