Awake Fiberoptic Intubation Research Articles

Hemodynamic Responses and Safety of Sedation Following Premedication with Dexmedetomidine and Fentanyl during Fiberoptic-assisted Intubation in Patients with Predicted Difficult Airway.

Background:Awake fiberoptic intubation (AFOI) is the gold standard for the management of predicted difficult airway, and inappropriate sedation is a major cause leading to its failure.Aims:The primary objective was to compare the heart rate (HR) changes that accompany AFOI following sedation with dexmedetomidine and fentanyl. Secondary objectives included comparison of changes in blood pressure, patient comfort, ease of intubation, and degree of sedation.Settings and Designs:This prospective double-blinded randomized study was conducted in a tertiary care institution.Subjects and Methods:Forty patients with anticipated difficult airway requiring AFOI were included in the study. Group A received dexmedetomidine 1 μg/kg whereas Group B received fentanyl 2 μg/kg. After topical anesthesia of the airway, AFOI was performed.Statistical Analysis Used:Fisher's exact test, independent two-sample t-test, and Mann–Whitney U-test were used as applicable.Results:The hemodynamic parameters were comparable in both the groups except at 1 min postintubation when fentanyl group had significantly higher HR. There were lower alertness and muscle tone scores in dexmedetomidine group. Total comfort score was significantly higher in fentanyl group. Though more patients in dexmedetomidine group showed that no reaction to intubation and more patients in fentanyl had slight grimacing, the difference was insignificant. The ease of intubation was similar in both the groups.Conclusion:Though dexmedetomidine1 μg/kg and fentanyl 2 μg/kg premedication results in comparable hemodynamics and ease of intubation, in view of enhanced patient comfort, dexmedetomidine premedication is advantageous in patients with anticipated difficult airway undergoing AFOI.

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.

A Comparative Study of Dexmedetomidine (1 mcg/kg) and Fentanyl (2 mcg/kg) with Dexmedetomidine (1 mcg/kg) Alone for Sedation during Awake Fiberoptic Intubation

A Comparative Study of Dexmedetomidine (1 mcg/kg) and Fentanyl (2 mcg/kg) with Dexmedetomidine (1 mcg/kg) Alone for Sedation during Awake Fiberoptic Intubation

Role of Lignocaine Nebulization as an Adjunct to Airway Blocks for Awake Fiber-Optic Intubation: A Comparative Study.

Context:Airway management is a crucial skill and area of concern for the anesthesiologist. Awake fiber-optic intubation (AFOI) remains the gold standard in managing difficult airway. Anaesthetizing the airway along with psychological assurance is the mainstay for Preparation of AFOI. Different topical and regional techniques have been developed to subdue reflexes and facilitate AFOI.Aim:This randomized controlled study was performed to evaluate the effectiveness of using lignocaine nebulization in addition to specific airway blocks for AFOI.Methodology:This was a comparative study conducted in 60 patients with difficult airway (LEMON score >2) and randomly allocated into two groups of 30 each. Group LB and Group NB received nebulization of 2% lignocaine 4 mL and 0.9% normal saline 4 mL, respectively. Both groups were then given airway blocks as bilateral superior laryngeal (2% lignocaine 1–2 mL each) and transtracheal (2% lignocaine 4 mL) block. Two puffs of 10% lignocaine to nose and postnasal space on each side were given in both groups. Fiber-optic bronchoscopy (FOB)-guided tracheal intubation was Performed. Vital parameters, side effects, bronchoscopy-guided intubation time and other parameters as intubation grading scale, patient comfort score, satisfaction score were recorded. Chi-square test and unpaired t-test were used for statistical analysis.Results:Statistically, no significant differences were found in hemodynamic parameters, demographics, intubation time, and intubation grading scale in both groups. However, overall patient comfort and satisfaction score was better in Group LB.Conclusion:Upper airway blocks provide adequate anesthesia for awake FOB, but when lignocaine nebulization is added to these blocks, it improves the quality of anesthesia and patient satisfaction.

A Case of Awake Fiber Optic Intubation Using DEX and a Translaryngeal Block for Enlarged Reoperative Surgery Performed Ten Days after an Initial Operation

A Case of Awake Fiber Optic Intubation Using DEX and a Translaryngeal Block for Enlarged Reoperative Surgery Performed Ten Days after an Initial Operation

To Compare the Efficacy of Local Anaesthetic Administration via Spray as you Go Technique and Ultrasonic Nebulisation for Awake Fiberoptic Intubation

To Compare the Efficacy of Local Anaesthetic Administration via Spray as you Go Technique and Ultrasonic Nebulisation for Awake Fiberoptic Intubation

Pits and pearls in the management of giant goiters

Objective: Giant goiters invariably have been neglected by the patients allowing them to grow to huge sizes. Usually, these are slow growing and are not troublesome, and hence, the patients ignore them. The treatment of such goiters is surgery. However, when these become >10 cm, they pose challenges to the patient, the anesthetist, and foremost the surgeon. Materials and Methods: We present here a single-institutional experience of managing 13 monster goiters. Harmonic scalpel and bipolar cautery were used intraoperatively. The surgical loupes were used in all cases for identification of the nerves. Their clinical presentation, salient symptoms and our experience, and key factors affecting successful outcomes were analyzed. Results: Ten patients had benign lesion and three harbored malignancy. All patients were made euthyroid before surgery except one in whom the indication for surgery was thyrotoxicosis. All patients underwent awake fiber-optic intubation. Four patients underwent total thyroidectomy, two underwent hemithyroidectomy, and remaining underwent subtotal thyroidectomy. One patient required sternotomy for retrosternal extension of the goiter. Harmonic scalpel and bipolar cautery were used intraoperatively. Surgical loupes were used in all cases for identification of the nerve. In all cases, recurrent laryngeal nerve was identified. Tracheomalacia was noted in two patients, and only one of them had to be tracheostomized postoperatively. Conclusion: Anatomy was found to be distorted in all our cases. Identifying the nerve was difficult due to distorted anatomy. Transient hypocalcemia was a consistent feature in spite of identifying the parathyroids and preserving its blood supply. Cases with tracheomalacia and bilateral vocal cord palsy can pose challenge for extubation, and tracheostomy needs to be considered in them.

Topicalisation of airway for awake fibre-optic intubation: Walking on thin ice.

Topicalisation of the airway by various techniques has routinely been recommended for awake fibre-optic bronchoscopy in cases of difficult airway. However, topicalisation by itself can cause airway obstruction by decreasing the tone of the laryngeal muscles and causing a dynamic air inflow obstruction. Two cases of difficult airway are illustrated where anaesthetising upper airway with nebulisation with 4% lignocaine (Xylocaine™) or 2% lignocaine (Xylocaine™) jelly resulted in stridor and upper airway obstruction. This is the first reported case of airway obstruction after lignocaine (Xylocaine™) jelly. We would like to highlight that topicalisation of airway, once thought as a relatively safe technique, can cause airway collapse if not detected and anticipated at the earliest. Pre-operative spirometry and airway ultrasonography can be useful in detecting the patients at risk of developing airway obstruction. Using a nasopharyngeal airway during topicalisation can serve as a valuable device in preventing total airway obstruction in susceptible patients.

Anaesthetic Management of a Patient with a Mobile Pedunculated Oropharyngeal Mass

As an anaesthesiologist, who faces several challenges in the Operating Room (OR), difficult intubation seems to be the most arduous. Anticipated difficult intubation if not planned well can be both cumbersome and disastrous. We describe the successful management of a case of anticipated difficult intubation due to a rare oropharyngeal mass, which was mobile and moved with respiration, arising from the left lateral wall of oropharynx. We used the technique of awake Fibreoptic Intubation (FOI) for intubating the trachea with dexmedetomidine infusion for sedation. Clinical findings and radiological imaging was used for assessment of difficult airway. Managing a case of difficult airway is highly individualised and meticulous planning is required in anticipated cases. A difficult airway complicates up to one tenths of cases of elective general anaesthesia. Such situations can be anticipated and tackled by fibreoptic flexible bronchoscopy assisted tracheal intubation.

Anaesthesia and orphan disease: airway and anaesthetic management in Huntington’s disease

We present a case that highlights the issues surrounding the delivery of a safe general anaesthetic to a patient with Huntington’s disease (HD) and bulbar dysfunction. In the case of...

RETRACTED: Comparative study between dexmedetomidine, magnesium sulphate and fentanyl as sedatives throughout awake fiberoptic intubation for patients undergoing cervical spine surgeries

Available online 3/22/2018This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://https://www.elsevier.com/about/our-business/policies/article-withdrawal).This art...

Proposal for a Protocol for Awake Fiberoptic Intubation in Adult with Dexmedetomidine

Fiberoptic intubation with the awakened patient (Awake Fibreoptic Intubation [AFOI]) is the gold standard technique for difficult airway management. The threshold for adopting AFOI depends, to some extent, on the competence of the person who will perform the intubation.

Current practice for awake fibreoptic intubation - asking the right questions

Current practice for awake fibreoptic intubation - asking the right questions

Anaesthetic management of Ludwig’s angina in a full term pregnant patient

We report a case of drainage of Ludwig’s angina in a pregnant patient conducted under general anaesthesia using awake fibreoptic intubation with least possible anaesthetic drugs.

Successful tracheal intubation with video laryngoscope when awake fiberoptic bronchoscopy failed in a patient with hypopharyngeal mass

Video laryngoscope is one of best alternative in managing difficult airways. Our patient presented with left side neck pain and hoarseness of voice for three months, dysphagia to solids for two months. Computed tomography revealed large hypopharyngeal mass and a diagnosis of carcinoma of hypopharynx was made. As endoscopic Ryle’s tube insertion by gastroenterologist was unsuccessful so he was posted for Feeding jejunostomy under general anaesthesia. We anticipated difficult endotracheal intubation. Our first attempt to secure airway with awake fiberoptic bronchoscopic intubation was unsuccessful. Using an alternative method with bougie and video laryngoscopy, the trachea was successfully intubated. In rare clinical scenario fiberoptic bronchoscopic intubation may fail, hence we need to be prepared with the backup plan for airway management. A video laryngoscope might be useful in such situations.

Dexmedetomidine and general anesthesia: a narrative literature review of its major indications for use in adults undergoing non-cardiac surgery.

In Europe, dexmedetomidine has marketing approval only for sedation in intensive care units. However, its use during general anesthesia has been widely reported. The aim of this narrative review is to draw a picture of potential indications in anesthesia. We searched in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using the keywords "Dexmedetomidine, Dexdor, Precedex and Dexdomitor." The research ended in December 2016. Studies were eligible for inclusion if they reported the use of dexmedetomidine in adults receiving general anesthesia. We excluded studies related to cardiac surgery and studies reporting the use of dexmedetomidine as an adjuvant of locoregional anesthesia. Several potential uses for dexmedetomidine during general anesthesia are described, especially: awake fiber optic intubation, the sparing effect of dexmedetomidine on hypnotic and opioid drugs, prevention of postoperative pain, nausea and vomiting and shivering, improvement of postoperative sleep and postoperative recovery, opioid-free anesthesia, use in craniotomy, endovascular stroke treatment and drug-induced sleep endoscopy. A protective effect against cardiac complications, an anti-inflammatory effect, and side effects, particularly bradycardia, are also described. The properties of dexmedetomidine lead to its use for elective indications such as awake fiberoptic intubation and neurosurgical anesthesia. New topics are under debate. These subjects must be studied thoroughly because of their implication in the patients' surgical course. These advantages must be weighed against the major drawback of dexmedetomidine administration which is the potential for hemodynamic abnormalities.

Clinical application of a novel endoscopic mask: a randomized controlled, multi-center trial in patients undergoing awake fiberoptic bronchoscopic intubation

BackgroundAwake fiberoptic bronchoscopic tracheal intubation is usually regarded as an effective method in the management of predicted difficult airway. Hypoxia during awake nasal fiberoptic bronchoscopic intubation leads to discontinuation of the procedure, prolonged manipulation time and increased risk of severe complications. The main aim of the study was to test whether the novel endoscopic mask is helpful for hypoxia during the intubation.MethodsThis was a randomized, controlled, multi-center study. 55 patients were recruited, but one patient was lost to follow-up. Finally, 54 patients (19 man and 35 women) were analyzed. After entering the operating room, nasal catheter oxygen-providing was given in the control group, and the treatment group received endoscopic mask oxygen-providing, with a flow rate of 3 L/min, lasting into the end of the intubation. Primary outcomes included mean arterial pressure, heart rate, minimum pulse oxygen saturation and incidence of pulse oxygen saturation ≤ 90%. Secondary outcomes included number of intubation attempts and time to intubation. All outcomes were finally measured.ResultsMinimum pulse oxygen saturation during awake nasal fiberoptic bronchoscopic tracheal intubation was significantly higher in the endoscopic mask intubation group (91.7% ± 4.7%) than that the nasal catheter intubation group (87.6% ± 8.2%, P = 0.031. Furthermore, the incidence of pulse oxygen saturation ≤ 90% was significantly lower in the endoscopic mask intubation group (20.0%, 5/25) than that in the nasal catheter intubation group (51.7%, 15/29, P = 0.037). But mean arterial pressure of during intubation was significantly higher in the endoscopic mask group (100.0 ± 13.3 vs 90.3 ± 21.8, P = 0.049). In addition, there were no differences in the number of intubation attempts (P = 0.45) or time to intubation between the two groups (P = 0.38).ConclusionsThe endoscopic mask was safely used in awake fiberoptic bronchoscopic tracheal intubation, with advantages of stable blood pressure and potential prevention of desaturation. Beginners for the intubation procedure and patients at high risk of hypoxia could benefit from the use of the endoscopic mask.Trial registrationTrial registration: www.chictr.org.cn. Registration No.: ChiCTR-TRC-13004086. Date of Registration: 8th, Sep, 2013.

A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre.

Contemporary data are lacking for procedural practice, training provision and outcomes for awake fibreoptic intubation in the UK. We performed a prospective cohort study of awake fibreoptic intubations at a tertiary centre to assess current practice. Data from 600 elective or emergency awake fibreoptic intubations were collected to include information on patient and operator demographics, technical performance and complications. This comprised 1.71% of patients presenting for surgery requiring a general anaesthetic, with the majority occurring in patients presenting for head and neck surgery. The most common indication was reduced mouth opening (26.8%), followed by previous airway surgery or head and neck radiotherapy (22.5% each). Only five awake fibreoptic intubations were performed with no sedation, but the most common sedative technique was combined target-controlled infusions of remifentanil and propofol. Oxygenation was achieved with high-flow, heated and humidified oxygen via nasal cannula in 49.0% of patients. Most operators had performed awake fibreoptic intubation more than 20 times previously, but trainees were the primary operator in 78.6% of awake fibreoptic intubations, of which 86.8% were directly supervised by a consultant. The failure rate was 1.0%, and 11.0% of awake fibreoptic intubations were complicated, most commonly by multiple attempts (4.2%), over-sedation (2.2%) or desaturation (1.5%). The only significant association with complications was the number of previous awake fibreoptic intubations performed, with fewer complications occurring in the hands of operators with more awake fibreoptic intubation experience. Our data demonstrate that awake fibreoptic intubation is a safe procedure with a high success rate. Institutional awake fibreoptic intubation training can both develop and maintain trainee competence in performing awake fibreoptic intubation, with a similar incidence of complications and success compared with consultants.

Current practice for awake fibreoptic intubation ‐ some unanswered questions

Current practice for awake fibreoptic intubation ‐ some unanswered questions

Optimal dosage of dexmedetomidine for sedation during awake fiberoptic intubation in elder patients

Objective Exploring the effect and the optimal dosage of dexmedetomidine(Dex) during fiberoptic intubation in elder patients. Methods One hundred and twenty patients, ASA Ⅱ or Ⅲ, were randomly divided into four groups with the random number table (n=30): D1, D2, D3 and D4. Four groups received Dex loading dose of 0.2, 0.4, 0.6, 0.8 μg/kg respectively, all the dose were given in ten minutes, then followed with 0.2 μg·kg-1·h-1. MAP, HR, SpO2 maintenance. Observer′s assessment of alertness/sedation(OAA/S) score were recorded at baseline(T0), the time before intubation (T1), the time when bronchofiberscope reaching glottis(T2), 1 min after intubation (T3), 3 min after intubation (T4) and 10 min after intubation (T5). Intubation time, intubation tolerance, and satisfaction rate were also recorded. Results Compared with T0, OAA/S decreased significantly at T1-T5 in group D1, D2, D3 and D4(P<0.05), MAP decreased significantly in group D2, D3 and D4(P<0.05), HR increased significantly at T2 in group D1 and D2(P<0.05). Compared with D1, OAA/S, HR, MAP decreased significantly at T2-T5 in group D3 and D4(P<0.05). Compared with D2, OAA/S decreased significantly at T4-T5 in group D4. MAP and HR were decreased significantly at T2-T5 in group D4. The incubation success rates of 4 groups were 100%. The intubation time in group D2, D3 and D4 were significantly shorter than group D1(P<0.05). Group D2, D3 and D4 were significantly calmer and more cooperative during waking time for fiberoptic incubation, they were also more satisfied with the awake fiberoptic incubation than group D1(P<0.05). Conclusions Dex at a loading dose 0.4-0.6 μg/kg intravenously can be used safely in bronchofibroscopy for elder patients with less cardiovascular and respiratory depression and with more tolerance and satisfaction. Key words: Dexmedetomidine; Aged; Bronchoscopy