Awake Fiberoptic Intubation Research Articles

Use of dexmedetomidine and low-dose ketamine as conscious sedation for fibreoptic bronchoscopy intubation for temporomandibular joint ankylosis secondary to an unsuspecting childhood trauma: a case report

Airway management in the paediatric population is known to be challenging due to its unique anatomical and physiological differences. Maxillofacial injuries further complicate airway management. To date, there is limited evidence to support the technique of airway management and the choice of drugs used in the paediatric population. This case report aims to describe the technique of conscious sedation using dexmedetomidine and ketamine to perform an awake fibreoptic intubation in the case of an 8-year-old boy with limited mouth opening due to a temporo-mandibular joint ankylosis secondary to childhood trauma. The endpoint of this case report showed that this technique proved effective with a good margin of safety in this paediatric patient with an airway concern. Further studies are needed to validate this observation.

Comprehensive Case Study on Awake Fiberoptic Intubation for Ameloblastoma with a Challenging Airway

Comprehensive Case Study on Awake Fiberoptic Intubation for Ameloblastoma with a Challenging Airway

Fatal Necrotizing Fasciitis Mediated by Escherichia coli After Parotidectomy and Neck Dissection: A Case Report and Review of the Literature.

Necrotizing soft tissue infection (NSTI) is a rare, but life-threatening, complication of head and neck surgery. We present a 70-year-old male with a history of immunosuppression who presented with polymicrobial NSTI following parotidectomy and neck dissection for cutaneous squamous cell carcinoma. The objective of this report was to promote awareness for NSTI following parotidectomy and selective neck dissection and highlight the management measures that can optimize survival outcomes. We performed a database search that identified 1,025 citations, of which 5 articles described classified as craniocervical necrotizing fasciitis following major head and neck surgery. Consent was obtained from the patient for inclusion in the research study and Institutional Review Board approval was waived. Our literature review yielded 6 cases of craniocervical necrotizing fasciitis following major head and neck surgery. This NSTI, however-unlike the others previously reported-was predominantly mediated by Escherichia coli, a bacterium associated with elevated mortality rates. Despite immediate awake fiberoptic intubation, repeated surgical debridement, and empirical antibiotic therapy, he deteriorated rapidly and was withdrawn from life-support on postoperative day seven. Prophylactic antibiotics, airway management, prompt diagnosis, and surgical debridement are critical for limiting mortality in NSTI of the head and neck.

Managing difficult airway in a post burn neck contracture: A case report

Post burns neck contracture is always considered a difficult airway and requires meticulous planning for proper management. Awake fiberoptic intubation (AFOI) have been gold standard for managing difficult airways [1]. Here we will discuss a case of difficult airway due to post burn contractures at the neck posted for debridement and Split Skin Grafting (SSG) for Marjolin’s ulcer at the nape of the neck. Internal changes in the airway due post inhalational injury fibrosis proved the major cause of difficulty and following traditional clinical teachings helped in successful management of airway.

Comparison of Dexmedetomidine and Nalbuphine on Intubating Conditions and Hemodynamic Responses During Awake Fiberoptic Intubation: A Randomized Study

Background: The pre-requisites to a successful awake fiberoptic intubation (AFOI) include adequate psychological and pharmacological preparation of the patient. This study aims to compare two pharmacological agents, dexmedetomidine and nalbuphine, in addition to nebulization and airway topicalization, for intubating conditions during AFOI.
 Methods: Sixty consenting patients belonging to ASA I/II, MPC I/II, age-group of 18-60 years weighing between 40-70 kgs requiring general anaesthesia with endotracheal intubation were randomly allocated to one of the two groups. Patients received dexmedetomidine 1µg/kg i.v. (group D) or nalbuphine 0.2 mg/kg i.v. (group N) over 10 min before intubation. Fiberoptic intubation was attempted. Intubating conditions were assessed in terms of sedation score, cough score and post-intubation score. Hemodynamic responses, lignocaine and propofol requirement were also recorded. Repeated measure ANOVA, Tukey’s test, unpaired t test, Chi‑square test or Fisher’s exact test were used for data analysis. A P < 0.05 was considered significant.
 Results: Sedation score (P = 1.000), cough score (P = 0.165) and post‑intubation score (P = 0.157) were comparable among the two groups. Hemodynamic responses, propofol and lignocaine requirements were also comparable.
 Conclusion: Both intravenous dexmedetomidine and nalbuphine provide good intubating condition with minimal adverse effects on haemodynamic profile during awake fibreoptic intubation.

Awake Nasal Fiberoptic Intubation in Lateral Position for Severely Obese Patients with Anticipated Difficult Airway: A Randomized Controlled Trial.

Obesity is a well-recognized risk factor for difficult intubation. To safely manage and overcome airway challenges in severely obese patients with a suspected difficult airway, awake fiberoptic intubation is recommended. We aimed to investigate the utility of awake nasal fiberoptic intubation in severely obese patients with suspected difficult airway while positioning them in the lateral decubitus position. This randomized controlled trial compared lateral and supine positions for awake nasal fiberoptic intubation in severely obese patients with an anticipated difficult airway by assessing the success rate, time needed to secure the airway, peri-procedural adverse events, and postoperative satisfaction of patients. Sixty patients with a median age of 37 [inter-quartile range (IQR): 29-44] years were included, of which 47 (78.3%) were females. The median body mass index (BMI) was 45.5 [IQR: 42.5-50.8] kg/m2. The success rate of fiberoptic intubation was 100% in both groups. The time needed to successfully secure the airway was 188 [148.8-228.8] seconds (s) in the lateral position, compared to 214.5 [181.8-280.5] s in supine position (p = 0.019). Intraprocedural cough was more common in the supine position group (n = 8; 26.7%), compared to the lateral position group (n = 3; 10%; p = 0.095). Postoperative sore throat was more common in the lateral position group (n = 12; 40%) compared to the supine position (n = 5; 16.7%; p = 0.045). In conclusion, Intubation in the lateral position is a promising technique that is equivalent to the routine supine position during fiberoptic intubation. In fact, intubation in the lateral position took less time to successfully secure the airway.

Incidence, causes, and management of failed awake fibreoptic intubation-A retrospective study of 833 procedures.

Awake fibreoptic intubation has been considered a gold standard in the management of the difficult airway. However, failure may cause critical situations. The aim of this study was to investigate the incidence and causes of failed awake fibreoptic intubation at a tertiary care hospital. The study was conducted at St. Olav University Hospital in Trondheim, Norway. Problems occurring during anaesthesia are routinely recorded in the electronic anaesthesia information system (Picis Clinical Solutions Inc.), including difficult intubations. We applied text search on all anaesthesia records between 2011 and 2021 and identified 833 awake fibreoptic intubations. The anaesthesia records were examined to identify failed awake fibreoptic intubations, the cause of failure and how the airway ultimately was secured. Among 233,938 patients who received anaesthesia, 90,397 received tracheal intubation and 833 received awake fibreoptic intubation. Twenty-nine of the procedures failed. In nine patients the failure caused loss of airway control with desaturation and hypoventilation. The major causes of failure were dislodged tube after induction of general anaesthesia (n = 8), patient distress (n = 5), tube not able to pass (n = 5), and airway bleeding (n = 3). The situations were primarily solved using direct laryngoscopy, with or without bougie, or with video laryngoscopy. Tracheostomy was performed in four patients. Awake fibreoptic intubation failed in 3.5% of patients, most often due to dislocation, problems passing the tracheal tube, or patient discomfort. The failure rate was higher than in previous studies.

A Randomized Comparison of Intravenous Versus Nebulized Routes for Administering Dexmedetomidine and Ketamine Combination to Facilitate Awake Fibreoptic Intubation.

Introduction Awake fibreoptic intubation is a technique used to secure the airway of patients who are havingpredicted difficult intubation. We compared two routes, intravenous and nebulized, for administering a combination of ketamine and dexmedetomidine to patients requiring sedation for fibreoptic intubation. Methods and materials After approval of the institutional ethics committee, 64 patients between 18 and 60 years belonging to the American Society of Anesthesiologists physical status I or II and having predicted difficult airway were randomized to receive study medications through either intravenous (group I, n = 32) or nebulized (group N, n = 32) routes. Group I patients were given a combination of ketamine and dexmedetomidine through intravenous route. Group N patients were nebulized with a combination of ketamine and dexmedetomidine. The time required for awake fiberoptic intubation was the primary outcome variable. In addition, sedation score, cough severity, patient tolerance, intubating condition, hemodynamic changes, recall of events and discomfort during intubation, and any adverse events in the perioperative period were also compared. Results Compared to group N, the time needed to intubate the patients was significantly less in group I (75.69 ± 10.83 versus 49.19 ± 3.60 seconds, p < 0.001). Observer assessment sedation/alertness score (p < 0.001), cough severity (p < 0.001), patient tolerance (p < 0.001), and intubating condition (p = 0.001) were statistically significant, all conditions being better in group I. Patient discomfort and recall of the procedure were statistically similar between the groups. Conclusions The efficacy of a combination of dexmedetomidine and ketamine through the intravenous route is better than the nebulized route for patients undergoing awake fibreoptic intubation.

We must not sacrifice anaesthesia rotations as part of emergency medicine training.

We must not sacrifice anaesthesia rotations as part of emergency medicine training.

Awake Fiberoptic Intubation in Patients with a Difficult Airway: Comparison of Ivory North Pole and PVC Portex Tubes

Awake Fiberoptic Intubation in Patients with a Difficult Airway: Comparison of Ivory North Pole and PVC Portex Tubes

Awake Fiberoptic Intubation

We may have many devices in this 21st century, which can be used to secure the airway in patients who have been predicted to have a difficult airway. There are many studies about difficult airways and suggested various devices such as flexible fiberoptic scope, video laryngoscope, and the specialized intubating laryngeal mask airway and they ended up concluding one device better than another. Furthermore, ET intubation requires continued practice and carries with it its own set of complications. Technical problems with the placement of endotracheal tubes have been the most frequent cause of anesthetic deaths in published analyses from all over the world. The basic responsibility of an anesthesiologist is to maintain adequate gas exchange in patients by securing a patent airway through a proper device. Fiberoptic bronchoscopy and intubation have the advantage of being easier, with shorter intubation time and continuous oxygenation and ventilation throughout the procedure, especially in the case of children. We report two such cases, where “Awake flexible fiberoptic-guided intubation” was considered the only desirable choice.

Comparative evaluation of lignocaine nebulization with and without dexmedetomidine for flexible videoendoscopic guided awake nasal intubation for general anaesthesia.

Awake fibreoptic intubation is considered a safe approach in airway management of a patient with difficult airway. Awake fibreoptic endoscopy needs appropriate anaesthesia of airway to suppress airway reflexes and prevent discomfort. We planned this study to evaluate effect of adding dexmedetomidine to lignocaine nebulization on conditions for awake videoendoscopic intubation. In this prospective randomized double blind controlled study, ninety six ASA grade I, II patients of either gender, aged 18-65 years, scheduled for elective surgeries under general anaesthesia, were randomly allocated into two groups, Group D and L to receive nebulization with 4% Lignocaine 5 ml + Dexmedetomidine 2 mcg/kg and 4% Lignocaine alone respectively, 20 min before procedure. Time taken to intubate the patient, ease of intubation assessed by cough severity score, patient comfort score, post-intubation patient satisfaction and hemodynamic changes were recorded and compared. Group D and L had comparable intubation time (196.8 ± 61.2 s) and (205.8 ± 52.2 s) (p = 0.437). Cough severity, patient comfort and quality of procedure with post intubation patient satisfaction score were significantly better in Group D. Haemodynamics parameters were better post nebulization in group D as compared to group L. Addition of Dexmedetomidine 2 mcg/kg with 4% Lignocaine during nebulization improves intubating conditions during awake flexible videoendoscopy in terms of ease of intubation, cough severity, patients comfort and satisfaction along with providing stable Haemodynamics profile.

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.

Acute lethargy, stridor, and hypoxemia in a young adult.

A young adult with intellectual delay presented to the emergency department (ED) from a group home via ambulance with altered mental status and respiratory distress. The patient was known to be non-verbal but definitely alert and interactive at baseline. On arrival, the patient was lethargic with frequent coughing and notable stridor, unable to obey commands. Emergency medical services reported SpO2 was initially 85%, but the hypoxemia had improved with supplemental oxygen administered via non-rebreather mask. Partial airway obstruction was suspected due to the stridor, and it was feared that the paralysis of rapid sequence intubation might result in a “can't oxygenate, can't ventilate” scenario. Preparations were made for immediate emergency airway management with a dual set-up for awake fiberoptic tracheal intubation and a cricothyroidotomy. Nasal cannula was applied at flush rate with SpO2 sustained at 100% throughout the procedure. Ketamine was used to facilitate fiberoptic nasopharyngoscopy, which identified a green foreign body obstructing a view of the entire glottis. Standard geometry video laryngoscopy was then employed to guide foreign body retrieval with Magill forceps and a DuCanto (SSCOR, Inc) suction catheter (Video 1). It was evident during removal that the foreign body was aspirated broccoli. The patient recovered from sedation and had no further need for supplemental oxygen in the ED. The patient was treated for aspiration pneumonia, admitted for observation, and was discharged at their neurologic baseline the next day. Incomplete foreign body airway obstruction (FBAO) is a time-sensitive emergency that mandates urgent intervention before progression to complete obstruction, which will always rapidly deteriorate to cardiac arrest. Immediate removal is critical to patients surviving with good neurologic outcomes in the event of a cardiac arrest.1 Operators should be prepared to follow well-established algorithms for the management of incomplete and complete FBAOs.2 Magill forceps have been part of airway management for over a century3 and are known to be effective in removing FBAOs in prehospital cardiac arrests.4 The DuCanto (SSCOR, Inc) suction catheter is a wide-bore rigid suction catheter that has been shown to effectively remove viscous liquid in simulated airway contaminations5 but was successful in removing smaller solid foreign bodies for this case. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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.

Learning awake fiberoptic intubation: use of a computerized mannequin simulator teaching

Background: Nasotracheal intubation is the most common method used to ventilate patients for oral maxillofacial surgeries. Fiberoptic intubation (FOI) is an essential skill for a wide range of healthcare providers, including anesthesiologists and emergency medicine physicians. However, proper programs and facilities for intubation training are insufficient.

AIRWAY MANAGEMENT IN LARGE THYROID MASS

Difculty with intubation will be seen in enlarged thyroid gland producing tracheal deviation, compression, or both. General anaesthesia in such cases are very risky as it may precipitate complete airway collapse and make mask ventilation and tracheal intubation impossible. We used different preparation of lignocaine in various concentrations for anaesthetizing the airway. Inj. Midazolam and fentanyl as sedatives. The combined use of local anaesthesia and mild sedation provided a calm relaxed environment, so smooth intubation was possible without any respiratory compromise. The safe options of airway management left in our case was: awake fiberoptic intubation

Anaesthetic considerations in Shrinking Man syndrome: two case reports

BackgroundShrinking Man syndrome (SMS) is a rare but often serious complication of dialysis-dependent end-stage renal disease, characterized by significant loss of height, bone pain, bone deformity, and skin itching. Patients with SMS always have abnormal facial changes and cardiovascular system damage (manifested by hypertension, hypotension, cardiovascular calcification, and valvular heart disease), which pose a great challenge to anaesthesiologists. The purpose of this report is to describe our anaesthetic experience regarding two patients with SMS combined with alterations of the airway and cardiovascular system.Case presentationWe describe two cases of SMS treated at West China Hospital, a tertiary care centre in Chengdu, China. All cases met the diagnostic criteria, which comprised 1) dialysis-dependent end-stage renal disease, 2) loss of height, and 3) bone pain and bone deformity. One patient had an anticipated difficult airway and moderate-to-severe mitral stenosis. The other patient presented with significant hypotension. Anaesthetic considerations included awake fibreoptic bronchoscopy-assisted tracheal intubation, real-time transoesophageal echocardiogram monitoring and individualized blood pressure management strategies.ConclusionThis case series highlights the importance of adequate preoperative assessment and preparation, as well as individualized anaesthetic management, in patients with SMS.

Comparison between Dexmedetomidine and Fentanyl on Intubating Condition to Facilitate Awake Oral Fibreoptic Intubation under Topical Anaesthesia – A Randomised Controlled Trial

Background and Aims: Awake fibreoptic intubation (AFOI) is the standard method of airway management in the anticipated difficult airway. While many drugs have been employed for sedation, there is no single drug that can be recommended as the drug of choice. Dexmedetomidine is characterised by effects of sedation, analgesia, amnesia and lack of respiratory depression. Hence, we hypothesised that dexmedetomidine should be suitable for AFOI and compared it to the control drug fentanyl. This study assesses the level of sedation and intubating conditions using dexmedetomidine or fentanyl during awake fibreoptic orotracheal intubation. Methods: Sixty adult patients, American Society of Anaesthesiology class I and II, who required orotracheal intubation during general anaesthesia with the normal airway were randomised to receive dexmedetomidine 0.6 μg/kg (Group A) or fentanyl 1.0 μg/kg (Group B) intravenous infusion for 10 min, after topical anaesthesia to the airway. A total of 60 patients were allocated, 30 patients in each group. The primary objective was to assess the intubating conditions with dexmedetomidine compared to fentanyl. Results: The intubation score for vocal cord movement (1.57 ± 0.68 in Group A vs 1.93 ± 0.75 in Group B) and cough (1.50 ± 0.78 in Group A vs 1.90 ± 0.72 in Group B), endoscopy score (2.17 ± 0.59 in Group A vs 2.47 ± 0.69 in Group B), sedation score (4.73 ± 0.5 in Group A vs 4.47 ± 0.57 in Group B) and patient satisfaction score (1.20 ± 0.41 in Group A vs 1.47 ± 0.68 in Group B) were statistically significant in patients receiving dexmedetomidine. During the procedure, there was a statistically and clinically significant increase in heart rate of 1.5% in Group A versus 22% in Group B, and an increase in mean arterial pressure of 1.95% in Group A versus and 10.27% in the Group B. Conclusion: Dexmedetomidine provided better intubation conditions than fentanyl, with greater haemodynamic stability, better sedation and greater patient satisfaction score compared to fentanyl during awake fibreoptic oral intubation.

Evaluate the efficacy of dexmedetomidine and fentanyl-midazolam combination on awake fiberoptic intubation in oral cancer surgery

Background: Awake fiberoptic intubation (AFOI) is the principal techniques in the management of difficult airway in oral cancer surgery. The aim of study was to evaluate the efficacy of dexmedetomidine and fentanyl-midazolam combination on awake fiberoptic intubation in oral cancer surgery. An ideal sedation regimen would ensure patient’s comfort and co-ordination attenuation of airway reflexes, hemodynamic stability and sedation. Methods: 60 patients of age group 18-60 years with American Society of Anaesthesiologist I and II posted for oral cancer surgery under general anaesthesia were randomly divided into two groups of 30 each in this prospective randomised and comparative study. Group-D (30 pt): Received an infusion of 1 µg /kg in 100ml Normal saline infusion IV over 10 min. Group-FM (30 pt): Received an infusion of fentanyl 2 µg /kg and midazolam 0.02mg/kg IV in 10ml of normal saline. All Patients were assessed for vocal cord movement, coughing, physical movement, comfort score, Ramsay sedation score, patient satisfaction score, and intubation time and hemodynamics variables. Results: The demographic characteristics were comparable in two groups (P>0.05).Group-D has more incidence of vocal cord opening than Group-FM. Group-D has less cough score than group-FM. Limb movement scores were more in group-FM than group-D. Group-D were more satisfied than group-FM (P=0.0002). RSS Score was significantly better in Group-D than in Group-FM (P=0.041). Group-D showed significantly reduced hemodynamic response to AFOI than group-FM. Conclusion: Dexmedetomidine is more effective than fentanyl-midazolam during AFOI, as it provides better intubation condition, hemodynamics stability and sedation.