Awake Fiberoptic Intubation Research Articles

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.

To evaluate the efficacy of dexmedetomidine infusion versus fentanyl infusion for sedation during awake fibreoptic intubation (AFOI)

Awake fibreoptic intubation (AFOI) is a great aid in an anticipated difficult airway like in maxillofacial surgeries. For providing patient’s comfort and cooperation various drugs are used. In this study we evaluated efficacy of Dexmedetomidine and Fentanyl for sedation during AFOI.It is randomized prospective double blind study. It was conducted on patients electively posted for maxillofascial surgery. 60 patients were randomly divided in two groups. Group D received Dexmedetomidine 1µg/kg and Group F received Fentanyl 2µg/kg over 10 minutes. Patients from both groups were prepared with intravenous glycopyrrolate0.2mg and nebulization with 4% lidocaine 4ml. Nasal AFOI was performed with spray (10% lidocaine) as you go technique. Parameters analysed are intubation score by cough score and vocal cord movement, post intubation score, Ramsay sedation score, hemodynamics with incidence of desaturation. Also satisfaction score and time taken for intubation were compared in 2 groups.Cough score, vocal cord movement, postintubation score, Ramsay Sedation Score (RSS), patient satisfaction score were favourable in dexmedetomidine group without much difference in time taken for intubation in both groups. Minimum hemodynamic response (p value<0.05) with less oxygen desaturation (p value< 0.05) is seen in dexmedetomidine group.Dexmedetomidine appeared to offer better intubation condition, better tolerance to intubation with higher patient satisfaction and hemodynamic stability. Also it provides adequate sedation without desaturation making it more effective for AFOI than fentanyl.

Alfentanil or dexmedetomidine, which one works better for awake fiberoptic intubation?

BackgroundDuring awake fiberoptic intubation, propofol, ketamine, benzodiazepines, opioids and dexmedetomidine are most commonly used, alone or in combination for sedation. The aim of this study was to compare the clinical efficacy of dexmedetomidine with alfentanil as a sole agent for patient-controlled sedation during fiberoptic intubation. MethodsSixty adults patients aged 30–55 years undergoing urologic surgery, were randomly allocated into two equal groups (n = 30) to receive either a loading dose of dexmedetomidine (1 μg/kg) over 10 min, followed by 0.5 μg/kg/h infusion or alfentanil a loading dose (20 μg/kg) over 60–90 s and then repeated 10 μg/kg every 1–2 min over 10–20 s to reach Ramsay Sedation Scale≥ 3. Primary outcome measures were intubation scores as assessed by vocal cord movement, limb movement, patient tolerance, cough, and patient cooperation immediately after intubation. Other parameters included time taken to achieve sedation, endoscopy time, intubation time and hemodynamic changes during this procedure. Patients’ satisfaction score with the procedure was also evaluated postoperatively. ResultsTime taken to achieve sedation, endoscopy time, intubation time in the alfentanil group was significantly shorter than the dexmedetomidine group (p ≤ 0.001). Limb movement and cough were more suppressed among the alfentanil group (p < 0.0001). Alfentanil provided better patient satisfaction than dexmedetomidine (p < 0.007). The level of patients’ tolerance and cooperation during and immediately after intubation were higher in the alfentanil group comparing dexmedetomidine (p < 0.0001 and p < 0.005; respectively). Nine patients in the dexmedetomidine group and two patients in the alfentanil group needed to be administered atropine (p < 0.02) to increase the heart rate, and four patients in the dexmedtomidine group and no patients in the alfentanil group needed ephedrine to increase their heart rate and blood pressure. Mean arterial pressure in the alfentanil group was significantly more stable than in patients who received dexmedetomidine (p, 0.0001). ConclusionsAlfentanil provided significantly more stable intubation scores for awake fiberoptic intubation compare with dexmedetomidine and patients were significantly more satisfied with fewer hemodynamic adverse effects.

Extensive facial burns: A case for awake fiberoptic intubation

Mask ventilation is the most basic step in airway management. There are certain situations where mask ventilation is difficult,1 but sometimes it may be really impossible as in this 30 year male patient with facial burns. He suffered from burns one and a half month back due to episode of seizure. Burns were present over face, neck, chest and shoulders. On examination, mouth opening was less than one cm. Teeth were loose. Neck movements were restricted. Left nares was only partially patent. Respiratory and cardiovascular systems were unremarkable. Relevant laboratory investigations were within normal limits. Mask ventilation was not feasible. So awake nasal fiberoptic intubation was planned.2,3 The procedure was explained to the patient and consent was taken for the same. He was given alprazolam 0.25 mg and ranitidine 150 mg at night and 2 h before surgery.

Anticipated difficult intubation in a septic shock patient

Difficult intubation can be a real challenge for any anesthesiologist. It is particularly hazardous and much more difficult to manage in an emergency situation.&#x0D; We present a case of a 72 years old male patient who was brought to ER with stridor and increasing shortness of breath. He was unstable hemodynamically on presentation, so was managed with adrenaline/salbutamol nebs, I/V fluids and intermittent boluses of vasopressors in the ER. ENT referral was also sought who tried a quick nasal scope, but couldn’t come to any conclusion. During neck examination they could feel a mass in the upper part of the neck and made a provisional diagnosis of a pharyngeal abscess. Portable chest x-ray was unremarkable and there was no time to do a CT neck to confirm the diagnosis due to the patient’s worsening condition. It was decided to rush the patient to OR for an awake fibre-optic intubation in the presence of ENT team in case if there was a need to do an emergency tracheostomy. The OR was prepared accordingly and the patient’s upper airway was sprayed and nebulized with lignocaine. A very small dose of remifentanil infusion was started for better tolerance of the procedure. Patient remained in an extremely critical condition with a systolic blood pressure 60-70 mmHg, despite of I/V fluids and metaraminol infusion. He also required intermittent boluses of 25 mics of adrenaline. There was no time for central venous access.

Correction to: Awake fiberoptic intubation with an epidural catheter in a morbidly obese patient

In the original publication of the article, the acknowledgment section was not included and provided in this correction.

AB227. Tackling a challenging intubation in a child: awake fibre-optic intubation using dexmedetomidine

: Awake fibre-optic intubation is uncommon, particularly in children. Dexmedetomidine is the sedating agent of choice in our centre for adult awake fibre-optic intubation. However, it has not been licensed for use in patients of less than 18 years and consequently, there is scarce research available concerning its use in this cohort. Nevertheless, dexmedetomidine is commonly used as a pre-medication in children in the intensive care setting. It is a selective alpha-2 adrenergic receptor agonist with both sedative and analgesic effects. Unlike most sedatives however, it causes minimal respiratory depression. Its duration of action is 30 minutes, and with its extended recovery time, post-sedation agitation is lessened. These factors contribute to the use of dexmedetomidine as our agent of choice for awake-fibre optic intubation; a procedure not deemed to be overly painful, but requires sedation. The case to be discussed is that of a 14-year-old male who presented to a hospital in the west of Ireland with a 3-day history of reduced mouth-opening, left-sided jaw stiffness, and coryzal symptoms. Following a variety of antimicrobial regimes and investigation by X-ray, nasoendoscopy, ultrasound and computed tomography, the patient was found to have a left lateral pterygoid abscess which required surgical drainage, under general anaesthesia. This posed obvious difficulties from an airway point of view, with the child’s mouth opening at less than one finger breadth. This challenge was overcome with the use of a dexmedetomidine infusion of 1.5 micrograms per kilogram per hour to perform an awake-fibre optic intubation. This procedure was atraumatic and performed without patient distress.

Awake fiberoptic intubation in patients with stenosis of the upper airways: Utility of the laryngeal nerve block.

Awake fiberoptic intubation (AFOI) is mandatory to manage difficult airways. Superior laryngeal nerve block (SLNB) could reduce risks and improve patient comfort. The aim of this study is to assess the procedural comfort of SLNB during AFOI in a population of patients undergoing upper airway oncological surgery. Forty patients were randomized into two groups and were treated with continuous infusion of remifentanil, topic anesthesia and intercricoid block. In the study group (=20), SLNB was performed with lidocaine (L-SLNB); in the control group (n=20) SLNB was performed using saline (S-SLNB). AFOI was more comfortable in the L-SLNB group compared to S-SLNB patients [FOICS ≤ 1 in 18 patients (90%) L-SLNB; 2 (10%) S-SLNB (P <0.001)]. Intubation was faster in L-SLNB (47.45 ±15.38 sec) than S-SLNB (80.15 ±37.91 sec) (p <0.001). The SLNB procedure during AFOI is a safe and comfortable procedure in a population of patients undergoing upper airways surgery. Time to intubation was shorter in L-SLNB than in S-SLNB.

Patient satisfaction survey as a tool towards quality improvement of sedation during Awake Fiberoptic Intubation

Patient satisfaction survey as a tool towards quality improvement of sedation during Awake Fiberoptic Intubation

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.

Novel technique for uninterrupted confirmation of endotracheal tube position for awake fiberoptic intubation

Oral Presentation, World Airway Management Meeting, 2019,13-16 November, Amsterdam, Netherland

Ergonomics of Awake Fibreoptic Intubation: A randomised cross-over manikin study

Ergonomics of Awake Fibreoptic Intubation: A randomised cross-over manikin study

Failed Awake Fibreoptic Intubation: What would you do next?

Failed Awake Fibreoptic Intubation: What would you do next?

A prospective randomized controlled study to assess the efficacy of fentanyl and dexmedetomidine for conscious sedation in awake fiberoptic intubation

Background: Awake fiberoptic intubation (AFOI) is usually the primary method for airway management in patients with anticipated difficult airway. To achieve optimal conditions for AFOI, the pharmacological agents chosen for sedation should be short acting and have little suppression of spontaneous ventilation. Aims and Objectives: The aim of this study was to compare the efficacy between dexmedetomidine and fentanyl for conscious sedation in AFOI. The objectives were to assess the intubating conditions, intubation attempts, and the hemodynamic responses between the groups receiving the two drugs. Materials and Methods: This prospective randomized double-blind study was done in 40 patients of the American Society of Anesthesiologists physical statuses I, II, and III, aged between 20 and 65 years. One group received fentanyl 2 mcg/kg infusion over 10 min. The other group received dexmedetomidine 1 mcg/kg infusion over 10 min. AFOI was done in both groups when patients achieved Ramsay sedation score of three. Time to sedation and time to intubation were noted. Intubating conditions were assessed with cough score. Heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation were also monitored for 30 min with 3 min interval after starting the drug infusion. The number of intubation attempts was also noted. Results: We found that the time to sedation and the time to intubation were shorter with dexmedetomidine than with fentanyl. There were no significant differences in cough score, number of intubation attempts, heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation between the groups. Conclusion: Both dexmedetomidine and fentanyl can be used to achieve adequate sedation for AFOI along with regional block and topical anesthesia. However, dexmedetomidine achieved target sedation faster compared to fentanyl enabling early intubation.

Airway nerve blocks as an adjunct to lignocaine nebulization for awake fiberoptic intubation

ABSTRACT Background Awake tracheal intubation (ATI) is becoming a gold standard in managing the difficult airway. Airway anesthesia is the cornerstone for the preparation of awake fiberoptic intubation (AFOI). Many topical and regional techniques have been developed to attenuate airway reflexes and facilitate AFOI. Glossopharyngeal superior laryngeal and recurrent laryngeal nerves must be blocked to attain adequate reflex abolishment. Aim This randomized controlled prospective study was performed to evaluate the effectiveness of adding airway nerve blocks to lignocaine nebulization for nasal AFOI. Methodology This was a comparative study conducted in 50 patients randomly allocated into two groups of 25 each: Group A and Group B; both received nebulization of 2% lignocaine 10 mL. Group B was then given airway blocks as bilateral superior laryngeal (2% lignocaine 1.5 mL each) and transtracheal (2% lignocaine 2 mL) block. Group A received the same airway nerve block by the same volume with normal saline 0.9%. Two puffs of 10% lignocaine to the nose and postnasal space on each side were given to both groups. Awake nasal fiberoptic intubation was performed. Vital parameters, such as intubation time, intubation condition, patient comfort scale, satisfaction score, and side effects, were recorded. Statistical analysis for both groups was done. Results Statistically, no significant differences were found in demographics and hemodynamics. Regarding intubation time and intubation condition scale, there was a significant improvement in Group B than in Group A. Also, overall patient comfort and satisfaction scores were significantly better in Group B than in Group A. Conclusion Upper airway lignocaine nebulization may provide adequate anesthesia for AFOI, but when supplemented by airway nerve blocks, it improves the quality of anesthesia and patient satisfaction.

Comparison of conventional technique versus modified tube first technique of awake nasotracheal fiber-optic intubation: A randomized control open-label trial

Background:Although the conventional awake fiber-optic nasal intubation is most commonly used in anticipated difficult tracheal intubation, it has several potential difficulties.Aims:The aim of this study is to compare another technique modified tube first (MTF) technique with the conventional one in terms of time taken, ease of glottis visualization, number of attempts needed, and complications.Settings and Design:This was a prospective, randomized, open-label trial conducted on 60 patients with an anticipated difficult airway undergoing oromaxillofacial surgery at a tertiary care center.Materials and Methods:The patients were randomized into the MTF and conventional technique groups. Times from insertion of the fiber-optic scope into nares till vocal cord visualization (T1) and from T1 to complete intubation (T2) were measured and compared.Statistical Analysis Used:Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 21.Results:Time taken to visualize glottis was significantly less in the MTF technique as compared to the conventional method (mean ± standard deviation = 108.6 ± 43.1 vs. 142 ± 49.2 s, respectively, P = 0.007). Similarly, the total time taken for nasotracheal intubation with modified technique is significantly less as compared to the conventional technique (P = 0.004). Furthermore, there is significantly better ease of glottis visualization (P = 0.001), higher success in minimal attempts (P = 0.02) with significantly lesser incidence of desaturation in MTF technique (P = 0.026).Conclusion:The alternative technique (MTF) is a quicker, easier approach with higher success rate and lesser complications for the placement of an endotracheal tube in a difficult airway scenario.

A randomized controlled study comparing dexmedetomidine-midazolam with fentanyl-midazolam for sedation during awake fiberoptic intubation in anticipated difficult airway

Background:Awake fibreoptic nasotracheal intubation is an effective technique for the management of patients with difficult airways. Adequate sedation with effective topicalization of the airway is important to overcome discomfort and achieve intubation successfully.Aim and Objectives:Our aim was to compare the effectiveness of dexmedetomidine-midazolam with fentanyl-midazolam infusion for providing conscious sedation during fibreoptic intubation in patients with anticipated difficult airway under topical anaesthesia.Materials and Methods:Thirty adult patients of ASA physical status classification I and II with anticipated difficult airway and planned for elective awake nasal fibreoptic intubation under conscious sedation were randomly allocated into two groups. Dexmedetomidine 1 μg.kg-1 diluted in 50 ml saline was infused in Group DM over 10 min and Fentanyl 2 μg.kg-1 diluted in 50 ml saline was infused in Group FM over 10 min. Topicalization of the airway was done in all patients. All patients were assessed for sedation score, ease of endotracheal tube placement, patient comfort and cooperation, tolerance to endotracheal tube, any adverse events and recall of procedure.Results:The score of the modified OAA/S was comparable between the groups (P > 0.05). Quality of AFOI was comparable in both groups (P > 0.05). The intubation time and first EtCO2 were significantly lower in dexmedetomidine group (P <0.05). Group DM also showed better hemodynamics and less episodes of desaturation than Group FM.Conclusion:Fentanyl-midazolam and dexmedetomidine-midazolam are both effective for awake fiberoptic intubation under topical anesthesia. Dexmedetomidine allows better endurance and more stable hemodynamics.

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.

Ultrasound tour of the anterior neck for the interventional pain physician

Ultrasound tour of the anterior neck for the interventional pain physician

Difficult airway where the anaesthesiologist succeeded but not the operating otorhinolaryngologist

Difficult laryngoscopy and intubation are life-threatening situations that are commonly seen in obese, short-necked patients. Amongst the various tools that can facilitate successful intubation in such patients, awake fibreoptic intubation is possibly the most popular and safe method. Rarely, the airway abnormality may be so severe that the operating otorhinolaryngologist may face difficulties in performing surgery once the airway has been secured, as happened in our patient.