Fiberoptic Nasotracheal 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.

Laryngeal Oncocytic Cyst: An Uncommon Incident

Oncocytic cysts of the larynx are benign and rare lesions constituting a pathologically distinct
 sub-group of cysts. In this report, we present a case with dyspnea with two large masses on
 false vocal cord identified by video laryngoscopy. Fiberoptic nasotracheal intubation revealed
 oncocytic laryngeal cysts.

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.

Risk factors affecting the difficulty of fiberoptic nasotracheal intubation.

BackgroundThe success rate of intubation under direct laryngoscopy is greatly influenced by laryngoscopic grade using the Cormack-Lehane classification. However, it is not known whether grade under direct laryngoscopy can also affects the success rate of nasotracheal intubation using a fiberoptic bronchoscpe, so this study investigated the same. In addition, we investigated other factors that influence the success rate of fiberoptic nasotracheal intubation (FNI).MethodsFNI was performed by 18 anesthesiology residents under general anesthesia in patients over 15 years of age who underwent elective oral and maxillofacial operations. In all patients, the Mallampati grade was measured. Laryngeal view grade under direct laryngoscopy, and the degree of secretion and bleeding in the oral cavity was measured and divided into 3 grades. The time required for successful FNI was measured. If the intubation time was > 5 minutes, it was evaluated as a failure and the airway was managed by another method. The failure rate was evaluated using appropriate statistical method. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were also measured.ResultsA total of 650 patients were included in the study, and the failure rate of FNI was 4.5%. The patient's sex, age, height, weight, Mallampati, and laryngoscopic view grade did not affect the success rate of FNI (P > 0.05). BMI, the number of FNI performed by residents (P = 0.03), secretion (P < 0.001), and bleeding (P < 0.001) grades influenced the success rate. The AUCs of bleeding and secretion were 0.864 and 0.798, respectively, but the AUC of BMI, the number of FNI performed by residents, Mallampati, and laryngoscopic view grade were 0.527, 0.616, 0.614, and 0.544, respectively.ConclusionUnlike in intubation under direct laryngoscopy, in the case of FNI, oral secretion and nasal bleeding had a significant effect on FNI difficulty than Mallampati grade or Laryngeal view grade.

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.

Comparison of Orotracheal versus Nasotracheal Fiberoptic Intubation Using Hemodynamic Parameters in Patients with Anticipated Difficult Airway.

Background:Both nasal and oral routes can be used for fiberoptic intubation. Often it leads to hemodynamic disturbances, which may have a significant effect in patients with limited cardiopulmonary reserve as well as with cerebrovascular diseases.Aims:The aim of the study was to evaluate whether there is a clinically relevant difference between the circulatory responses to oral and nasal fiberoptic intubation.Settings and Design:This was a prospective, randomized, and comparative study.Materials and Methods:In this study, a total of 90 patients with the American Society of Anesthesiologist physical status I and II of either sex in the age group of 18–60 years and having anticipated difficult airway (DA) posted for elective surgery under general anesthesia were randomly allocated into two groups. Patients underwent fiberoptic intubation via either oral or nasal route under sevoflurane anesthesia with bispectral index guidance. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), time taken to intubation, and need of maneuver were measured.Statistical Analysis Used:All the analyses were carried out on SPSS 16.0 version (Inc., Chicago, USA). Mean and standard deviation were calculated. The test of analysis between two groups was done by unpaired t-test.Results:Demographic and DA characteristics were similar in both the groups. Significantly (P < 0.01) lesser alteration in HR, SBP, DBP, and MAP was seen in oral fiberoptic intubation when compared to nasal fiberoptic intubation in the early phase of postintubation. Time taken to intubation was also significantly (P < 0.01) lesser in the oral route compared to the nasal route.Conclusions:Oral fiberoptic intubation causes less hemodynamic alteration and takes less time in comparison to nasal fiberoptic intubation.

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.

Magnesium Sulfate and Fentanyl for Facilitating Awake Fiberoptic Nasotracheal Intubation: A Randomized Study

Background: Various drugs have been used to facilitate awake fiberoptic intubation (AFOI). Although fentanyl is probably used most frequently, magnesium sulfate can provide muscle relaxation without respiratory depression and attenuate hemodynamic responses. Methods: We randomly allocated 20 patients of both sexes, aged 18 - 60 years, and ASA status I-II to receive fentanyl 2 μg/kg (group F) or magnesium sulfate 45 mg/kg (group M) before AFOI. The intubating conditions were evaluated by Ramsay sedation score (RSS), cough score, post-intubation score, additional topicalization requirement, and hemodynamic response. Oxygen desaturation, airway morbidity, recall of procedure, and the patient’s willingness to return for the same kind of anesthesia, if required, were also studied. Statistical analyses were done using SPSS V. 17.0 software. Numerical data were analyzed using independent and paired t-tests and categorical data using the chi-square test. P values of < 0.05 were considered significant. Results: RSS, cough score, post-intubation score, lignocaine dose, airway-related morbidity, and willingness to undergo the same kind of anesthesia for a second time were comparable between the two groups. Both drugs had comparable effects on hemodynamic response to intubation. However, the incidence of recall of the procedure was significantly lower in group F (P = 0.003). Conclusions: The degree of coughing during fiberoptic bronchoscopy, tolerance of the endotracheal tube after intubation, and the hemodynamic response to intubation were similar after the administration of either fentanyl 2 μg/kg or magnesium sulfate 45 mg/kg.

A comparison of the effectiveness of dexmedetomidine versus propofol-fentanyl combination for sedation during awake fibreoptic nasotracheal intubation

Introduction: In patients with anticipated difficult airway, awake fiber optic intubation (AFOI) is an established modality. Various drugs have been used to provide favourable intubating conditions with good patient comfort and cooperation. Commonly used agents are opioids and benzodiazepines along with the recent agents like dexmedetomidine. We undertook this study to compare dexmedetomidine against propofol-fentanyl combination for AFOI. Materials and Methods: A randomized prospective study was performed on sixty patients with anticipated difficult airway and allocated into two groups each containing thirty. Propofol-fentanyl (PF) group received initial bolus of inj propofol 0.5 mg/kg and fentanyl 0.5?g/kg followed by propofol infusion of 30µg/kg/min and dexmedetomidine (DEX) group received loading dose of 1µg/kg for 10 min and followed by maintenance infusion of 0.5?g/kg/h. We analyzed haemodynamics, saturation, Ramsay sedation score, rescue midazolam requirement, airway obstruction, patient tolerance and intubating conditions. Results: There was no difference in demographic variables between the two groups. PF group achieved higher mean Ramsay sedation score (RSS) during AFOI as compared to DEX group, (P?2) as compared to DEX group (40%) (p Twenty-three (76.7%) in DEX group had patent airway (score 1) compared to twelve patients (40%) in PF group (P Conclusion: Both PF and DEX provided comparable satisfactory intubating conditions for AFOI in terms of vocal cord and limb movement scores. However, PF combination provided lower cough scores and better patient tolerance scores. Dexmedetomidine offered better patent airway with spontaneous ventilation. Reduced hemodynamic response to intubation was achieved in both the groups, although PF group caused more hypotension during AFOI. No episodes of hypoxia was seen in both the groups. Keywords: Difficult airway, Awake fiberoptic intubation, Propofol-fentanyl, Dexmedetomidine infusion.

Comparison of two different tracheal tube designs for awake fibreoptic nasotracheal intubation

Comparison of two different tracheal tube designs for awake fibreoptic nasotracheal intubation

Refinement of the Transoral Approach to Craniovertebral Junction Malformations.

The transoral approach provides the most direct surgical corridor for treatment of congenital bony abnormalities that exert irreducible ventral compression of the cervicomedullary junction. In this paper, based on our experience with the transoral approach over the past three decades, we briefly describe the surgical strategies and the operative nuances that allow effective decompression of the craniovertebral junction (CVJ) while minimizing postoperative morbidity. The surgical strategy is dictated by the type and severity of the malformation. Fibre-optic nasotracheal intubation obviates the necessity of preoperative tracheostomy, and avoidance of a soft-palate incision significantly reduces oropharyngeal morbidity. When feasible, the atlas-sparing technique minimizes postoperative instability. The transoral transatlas approach is generally required in patients with severe basilar invagination and allows wider exposure of the anterior CVJ at the price of a higher incidence of postoperative instability. The transoral approach is extremely effective in providing excellent decompression of the anterior cervicomedullary junction in patients with fixed malformations. Tailoring the approach to the peculiar anatomy of each malformation reduces iatrogenic instability and minimizes postoperative complications.

A comparison of two doses of ketamine with dexmedetomidine for fiberoptic nasotracheal intubation.

Background and Aims:Flexible fiber-optic intubation is considered to be the gold standard for management of difficult airway. Fiber-optic intubation does require effective sedation and blunting of airway reflexes for which various drug regimens have been utilized in the past. In a quest to find the noble drug combination, we combined ketamine and dexmedetomidine in two different doses, to evaluate the clinical efficacy and safety profile of ketamine and dexmedetomidine for fiber-optic intubation.Materials and Methods:This prospective randomized study was conducted in 72 patients of 20–50 years’ age group of either sex with the American Society of Anesthesiologists Physical Status I and II with difficult airway. We compared two doses of ketamine 20 mg (Group I) and 40 mg (Group II) with a common dose of dexmedetomidine at 1 μg/kg body weight, given as an infusion over 10 min (a solution of 50 ml with normal saline). Sedation scores, hemodynamic variables in terms of blood pressure, heart rate (HR), and oxygen saturation were studied along with 24-h postoperative patient discomfort and recall of procedure.Results:Group II patients showed less variation from their baseline values in terms of HR (ranged between 0.73% and 4.75%) and mean arterial pressure (ranged between 0% and 3.97%) in comparison to Group I HR (ranged between 0.09% and 9.81%) and mean pressures (ranged between 0.3% and 10.38%). Discomfort during procedure (P < 0.001) and recall of procedure scale (P = <0.001) were found significantly better/lower in Group II as compared to Group I.Conclusion:Ketamine 40 mg in comparison to 20 mg with dexmedetomidine provides better hemodynamic conditions with better tolerance and lower recall to the fiber-optic intubation.

A Simple Method of Topicalisation to Facilitate Awake Fibreoptic Nasotracheal Intubation: Experience at a Tertiary Care Hospital.

A Simple Method of Topicalisation to Facilitate Awake Fibreoptic Nasotracheal Intubation: Experience at a Tertiary Care Hospital.

Clinical Comparative Study Between Dexmedetomidine, Magnesium sulphate and Ketofol versus Midazolam for Sedation During Awake Fiberoptic Nasotracheal Intubation in Predicted Difficult Air ways Patients

Background and objectives: Awake fiber optic intubation (AFOI) is recommended technique in securing the airway in predicted difficult airway patients with sedation. However, it is not easy to achieve a comfortable sedation so conscious sedation is the key for a successful AFOI. The goal of the study to compare different conscious sedation strategies aimed to improve comfort and safety in patients prepared for elective surgeries. Subjects and Methods: Case control, randomized controlled study in predicted difficult airway patients scheduled for elective surgery under GA carried out at AL-Azhar University Hospitals after approval by the local ethical committee. 120 patients of age group 18-60 years old with ASA I and II prepared for nasal (AFOI) under conscious sedation after giving their informed written consent to participate in our study. The patients were randomly assigned into 4 groups: Group dexmedetomidine (DEX), group ketofol, group magnesium sulfate and group midazolam. HR, MAP, Oxygen saturation and end tidal CO2 were monitored. Sedation score, patient tolerance, patient satisfaction and intubation score (vocal cord movement and coughing) were assessed. Results: All patients were successfully intubated by fiber optic and none of them developed bradycardia or reduced MAP more than 20% from the base line during intubation. Group DEX mild decrease in MAP and HR ( 0.05). Group ketofol and midazolam patients were sedated deeper after the start of the study drugs than group DEX and none of the patients were sedated to a score of < 2 (modified OAA/S score) in either of the groups. Group magnesium showed lighter sedation level significantly different with other groups. Conclusion: Study showed DEX provides optimum sedation without compromising airway or hemodynamic stability with favorable intubation time and less intubation attempts during AFOI in comparison to magnesium sulphate, ketofol and midazolam patients with better patient tolerance and satisfaction.

Clinical Comparative Study Between Dexmedetomidine, Magnesium sulphate and Ketofol versus Midazolam for Sedation During Awake Fiberoptic Nasotracheal Intubation in Predicted Difficult Air ways Patients

Background and objectives: Awake fiber optic intubation (AFOI) is recommended technique in securing the airway in predicted difficult airway patients with sedation. However, it is not easy to achieve a comfortable sedation so conscious sedation is the key for a successful AFOI. The goal of the study to compare different conscious sedation strategies aimed to improve comfort and safety in patients prepared for elective surgeries. Subjects and Methods: Case control, randomized controlled study in predicted difficult airway patients scheduled for elective surgery under GA carried out at AL-Azhar University Hospitals after approval by the local ethical committee. 120 patients of age group 18-60 years old with ASA I and II prepared for nasal (AFOI) under conscious sedation after giving their informed written consent to participate in our study. The patients were randomly assigned into 4 groups: Group dexmedetomidine (DEX), group ketofol, group magnesium sulfate and group midazolam. HR, MAP, Oxygen saturation and end tidal CO2 were monitored. Sedation score, patient tolerance, patient satisfaction and intubation score (vocal cord movement and coughing) were assessed. Results: All patients were successfully intubated by fiber optic and none of them developed bradycardia or reduced MAP more than 20% from the base line during intubation. Group DEX mild decrease in MAP and HR ( 0.05). Group ketofol and midazolam patients were sedated deeper after the start of the study drugs than group DEX and none of the patients were sedated to a score of < 2 (modified OAA/S score) in either of the groups. Group magnesium showed lighter sedation level significantly different with other groups. Conclusion: Study showed DEX provides optimum sedation without compromising airway or hemodynamic stability with favorable intubation time and less intubation attempts during AFOI in comparison to magnesium sulphate, ketofol and midazolam patients with better patient tolerance and satisfaction.

Awake Fiberoptic Nasotracheal Intubation of a Patient with Ankylosing Spondylitis Expected Difficult Intubation

Ankilozan spondilitte omurga kemiklerinin fuzyonu ile sirt ve boyunda esneklik kaybi gelisir. Hastaligin ileri evrelerinde servikal, torakal ve lumbal vertebralarin ankilozu nedeniyle havayolu yonetiminde zorluklarla karsilasilabilir. Bu sunumda, solunum sikintisi nedeniyle acil trakeostomi gerektiren ve agiz acikligi ile boyun hareketlerinin ileri derecede kisitli olusu nedeniyle zor havayolu beklenen ankilozan spondilitli bir hastaya uyanikken uygulanan fiberoptik nazotrakeal entubasyon anlatilmistir.

Comparison of Effectiveness of Dexmedetomidine versus Propofol during a wake Fibre-optic Naso-tracheal Intubation

Comparison of Effectiveness of Dexmedetomidine versus Propofol during a wake Fibre-optic Naso-tracheal Intubation

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 Study to Compare Efficacy of Two Different Doses of Dexmedetomidine during Awake Nasotracheal Fibreoptic Intubation in Patients with Difficult Airway

A Study to Compare Efficacy of Two Different Doses of Dexmedetomidine during Awake Nasotracheal Fibreoptic Intubation in Patients with Difficult Airway