Fiberoptic Orotracheal Intubation Research Articles

Successful fiberoptic orotracheal intubation by lifting large thyroid mass and tongue protrusion in left lateral position: a case report

Abstract Introduction Awake fiberoptic bronchoscopy has long been considered the criterion standard for the management of difficult airways because of large thyroid malignancies. After an unsuccessful attempt to intubate with a fiberoptic bronchoscope in the supine position, the decision to switch to the left lateral position was made. We present this case to propose the utilization of the lateral position for awake intubation. Case presentation We report a rare case of a patient with a large papillary carcinoma of the thyroid planned for surgical excision. The patient presented to our hospital with complaints of difficulty breathing while lying down in the supine position and oozing blood from the necrotic tissue. The breathing difficulties subsided in the lateral position. Conclusion We demonstrated how the left lateral position with an adjunct maneuver facilitates intubation in large thyroid malignancies.

Research on the Utilization of Multimodal Active Learning for Fiberoptic Orotracheal Intubation in the Standardized Training of Anesthesiology Residents: A Prospective Randomized Control Trial

Research on the Utilization of Multimodal Active Learning for Fiberoptic Orotracheal Intubation in the Standardized Training of Anesthesiology Residents: A Prospective Randomized Control Trial

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.

Use of laryngoscope blade as a rescue intubating airway during fiberoptic orotracheal intubation.

Use of laryngoscope blade as a rescue intubating airway during fiberoptic orotracheal intubation.

Awake fiberoptic orotracheal intubation: a protocol feasibility study.

ObjectiveTo assess the feasibility of an awake fiberoptic intubation (AFOI) protocol.MethodsWe enrolled 40 patients with simulated difficult intubation. The protocol consisted of conscious sedation (midazolam, 0.03 mg/kg and sufentanil, 0.1 µg/kg), regional anesthesia, and intubation. The time, first-attempt intubation success rate, hemodynamic parameters, blood oxygen saturation (SpO2), intubation amnesia rate, patient satisfaction, and relative complications were recorded.ResultsAFOI was completed in all patients. The average total AFOI time was 14.17 ± 1.47 minutes, and the time to placing the landmark-guided bilateral superior laryngeal nerve block was 1.24 ± 0.42 minutes. The first-attempt intubation success rate was 97.5%, and patient satisfaction was 90%. Blood pressure changed (<20%) briefly after administering conscious sedation. Heart rates did not change significantly, and SpO2 remained stable and ≥95%. Three patients had a sore throat, which resolved on postoperative day 1 without other complications. On postoperative day 1, 82.5% (33/40) of the patients had no recall of AFOI, and 17.5% (7/40) had only an indistinct memory.ConclusionsThe protocol was feasible with a high first-attempt intubation success rate and low complications rate. Hemodynamic parameters and respiration remained stable, with high patient satisfaction and effective amnesia.

Perioperative pain management of the patient with morbid obesity in bariatric surgery. Clinical report and literature review

Background. Anesthetic management of patients with morbid obesity during bariatric surgery presents a number of problems, including “difficult” vascular access, “difficult” airways, increased risk of aspiration, changes in the pharmacokinetics of anesthetics, and an increased risk of postoperative respiratory depression associated with opioids. Methods. Case description Patient 32 years old, height 162 cm, body weight 200 kg (body mass index 76.2 kg/m²) underwent surgical treatment for morbid obesity (gastroentero bypass) using combined anesthesia (general anesthesia with desflurane combined with epidural analgesia ropivacaine 2 mg/ml). Results. Ultrasound navigation was used to catheterize the peripheral vein and insert an epidural catheter. Also, due to the high risk of difficult airways (according to the MOSCOW TD scale — 4 points), the patient underwent fiberoptic orotracheal intubation with in consciousness with sedation by dexmedetomidine to level –1 on the Richmond excitation-sedation scale. Early activation of the patient was achieved by controlled anesthesia and multimodal analgesia in the postoperative period. Analgesia after surgery using prolonged epidural administration of 0.2 % ropivacaine at a rate of 4–8 ml/h, intravenous paracetamol 1 gram every 8 hours. 2 hours after the end of the operation, the patient sat down on the bed with her legs down and got up for the first time after 6 hours. On the second day, she was transferred to a specialized department with prolonged epidural analgesia, the duration of which was 72 hours. Complications were not observed in the postoperative period. The patient was discharged from the clinic on the eighth day after surgery in a satisfactory condition without active complaints. Conclusion. In this clinical case, the chosen tactics of postoperative analgesia made it possible to achieve good analgesia, conduct early activation of the patient, and begin early rehabilitation procedures.

Combining Videolaryngoscopy With Fiber-Optic Orotracheal Intubation for Inclusion in the Nonemergency Pathway of the Difficult Airway Algorithm.

As technology progresses, our clinical treatment options rise steadily. We are comfortable now with the handling of ready-to-use high-quality videolaryngoscopes and fiber optics, and there is increasing knowledge and practice that the combination of these 2 techniques has a high "rescue rate" in situations when fiber-optic intubation or videolaryngoscopic intubation fails. Therefore, we would recommend to specifically include this technique in the "difficult airway algorithm-nonemergency pathway," so it comes routinely into mind when faced with a "can ventilate, but cannot intubate" situation that warrants intubation for the surgical operation.

Awake fiberoptic orotracheal intubation using a modified Guedel airway in a patient with craniocervical instability and an anticipated difficult airway - A case report -

In patients with upper cervical instability, airway management may provoke subluxation of the craniocervical region and neurologic injury, and can be challenging for the anesthesiologist. Endotracheal intubation using a fiberoptic bronchoscope is frequently used in these patients to minimize spine motion, but this procedure may fail in patients with altered airway anatomy. When fiberoptic endotracheal intubation fails in these patients, optional intubation methods are limited. We describe successful awake fiberoptic orotracheal intubation using a modified Guedel airway divided in the midline for a 59-year-old man with an anticipated difficult airway, due to limited mouth opening, a nasopharyngeal tumor, and craniocervical spine instability after failure of conventional fiberoptic orotracheal intubation. Keywords: Airway; Bronchoscope; Guedel airway; Instability; Neck

RETRACTED: Proficiency of Dams Tulip-i® in awake fiberoptic orotracheal intubation for difficult airway

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief as it contains fabricated/falsified data. The Editor-in-Chief decision was based on the investigation by the Japanese Society of Anesthesiologists which concluded that no research was conducted and all the data including patient backgrounds were fabricated. The society also concluded that the corresponding author, Dr. Ueshima presented the names of the individuals not involved or only partially involved in research as lead authors, presented the names of the individuals not involved in research as co-authors and submitted papers without the agreement of the co-authors. The investigation report can be found here.

Comparison of Berman and Ovassapian Intubating airways for fiberoptic orotracheal intubation in anaesthetized patient

Background: Intubating oral airways are widely used during fibreoptic orotracheal intubationin order to improve the bronchoscopic visualisation of the glottis and facilitate the procedure. This study compares the visualisation of the glottic opening with bronchoscope using Berman or Ovassapian intubating airway.Methods: We conducted a randomised comparative prospective study one hundred twenty patients with no clinical indicators of the difficult airway. The two oral intubating Berman and Ovassapian airways were compared during fibreoptic endotracheal intubation in anaesthetized patients. The bronchoscopic view, bronchoscopic time, and the total time for intubation were compared.Result: The bronchoscopic view was significantly better with Berman intubating airway (unobstructed view 74%) as compared to the Ovassapian airway (unobstructed 38.4%) (p-value 0.002). The Berman airway provided a significantly shorter duration for visualisation of the vocal cord and intubation of trachea in comparison to the Ovassapian airway.Conclusion: Berman airway provided a better bronchoscopic view as well as shorter bronchoscopic and intubation time as compared to the Ovassapian airway.

Comparison between remifentanil and dexmedetomidine for sedation during modified awake fiberoptic intubation.

Cricothyroid membrane injections and the application of a coarse fiberoptic bronchoscope (FOB) below the vocal cords for topical anesthesia have a number of limitations for certain patients. Thus, the aim of the present observational study was to assess the effect of a novel modified topical anesthesia method using the effective sedation drugs, remifentanil (Rem) or dexmedetomidine (Dex), during awake fiberoptic orotracheal intubation (AFOI). In total, 90 adult patients, who had been classified as American Society of Anesthesiologists I–II, were included in the study. The patients had anticipated difficult airways and were to undergo orotracheal intubation for elective surgery. The patients were enrolled in the double-blinded randomized pilot study and received Rem or Dex for sedation during the modified AFOI procedure. The two groups received 2% lidocaine for topical anesthesia via an epidural catheter, which was threaded through the suction channel of the FOB. The main clinical outcomes were evaluated by graded scores representing the conditions for intubation and post-intubation. Additional parameters analyzed included airway obstruction, hemodynamic changes, time required for intubation, amnesia level and subjective satisfaction. All 90 patients were successfully intubated using the modified AFOI technique. The comfort scores and airway events during intubation did not significantly differ between the two groups. However, the Rem group experienced less coughing, and less time was required for tracheal intubation when compared with the Dex group. No statistically significant differences were observed in the changes to the mean arterial pressure and heart rate at any time point between the two groups. Therefore, the current study demonstrated that the modified AFOI method is feasible and effective for difficult airway management, and that Dex and Rem exhibit similar efficacy as adjuvant therapies.

A case report of anesthesia for a child with Hajdu–Cheney syndrome

Hajdu-Cheney syndrome is an extremely rare disorder characterized by progressive skeletal acro-osteolysis, which results in extremity fractures and scoliosis often requiring surgical treatment from childhood. A unique facial structure and deformity of the cervical spine is associated with a difficult airway. We report here a 10-year-old girl with Hajdu-Cheney syndrome who developed progressive basilar impression and medullary compression for which foramen magnum decompression was performed. After slow induction of anesthesia, we were able to perform fiberoptic orotracheal intubation via a VBM bronchoscope airway. This case report contributes to the accumulation of knowledge about anesthesia for this rare syndrome.

Anesthetic management for a patient with severe mento-sternal contracture: difficult airway and scarce venous access -A case report-

There are many problems in the anesthetic management of patients with scar contracture. In this case, a 41-year-old male with severe scar contracture on his face, neck, anterior chest, and both shoulders underwent surgery for resurfacing with flaps. We tried to awake fiberoptic orotracheal intubation with GlideScope® Video laryngoscope guide after surgical release of contracture under local anesthesia. We report a successful management of a patient with severe burn contracture achieved by combined effort of surgeons and anesthesiologists.

Use of a Modified Ovassapian Airway to Increase Mouth Opening for Fiberoptic Orotracheal Intubation in a Patient with Severe Trismus

To the Editor When the outside diameter of the endotracheal tube is greater than the interincisor distance, oral intubation between the teeth is impossible. We present a novel approach to increase the oral aperture in a patient with severe trismus. A modified Ovassapian airway was used as a wedge to increase mouth opening, enabling fiberoptic oral intubation. Written patient consent was obtained for this submission. A 67-year-old man with oral carcinoma presenting for mandibulectomy had undergone prior tumor resection and radiotherapy. Osteoradionecrosis caused marked trismus. Because of the recent placement of a drug-eluting stent for coronary artery disease, aspirin and clopidogrel were continued throughout the perioperative period to prevent stent thrombosis. Nasal tracheal intubation was undesirable because of the risk of epistaxis. His interincisor distance was 8 mm and it was impossible to fully insert an Ovassapian airway into the mouth. The airway was modified by cutting out the proximal ring of the intubating channel. It was then possible to insert the airway deeper into the oral cavity and advance as a slanted wedge, slowly increasing mouth opening to 12 mm (Fig. 1) and allowing successful awake fiberoptic orotracheal intubation. By achieving a modest increase in mouth opening, this modified Ovassapian airway enabled successful oral intubation.Figure 1: Modified airway inserted deeper into the mouth to increase interincisor distance.Angela Truong, MD Dam-Thuy Truong, MD Department of Anesthesiology and Perioperative Medicine University of Texas M.D. Anderson Cancer Center Houston, Texas [email protected]

Awake Glidescope® intubation in a patient with a huge and fixed supraglottic mass -A case report-.

Intubating patients with a huge, fixed supraglottic mass causing an obstruction of the glottis is difficult to most anesthesiologists. We attempted awake fiberoptic orotracheal intubation assisted by Glidescope® Videolaryngoscope (GVL) following topical anesthesia with 4% lidocaine spray and remifentanil infusion. The glottis could not be identified by the GVL view. However, by entering toward the right side of the mass with bronchoscope, the glottis was found. Due to stiffness of the mass, we were unable to further enter the area using the bronchoscope. Alternatively, we attempted to expose the glottis by GVL blade and then successfully intubated the patient by manually pressing the cricoids cartilage. GVL is nonetheless an excellent instrument in airway management compared to fiberoptic bronchoscope for patients with a huge and fixed supraglottic mass.

Spray-As-You-Go Airway Topical Anesthesia in Patients with a Difficult Airway: A Randomized, Double-Blind Comparison of 2% and 4% Lidocaine

We designed this randomized, double-blind clinical study to compare the safety and efficacy of 2% and 4% lidocaine during airway topical anesthesia with a spray-as-you-go technique via the fiberoptic bronchoscope. Fifty-two adult patients with a difficult airway were randomly assigned to 1 of 2 study groups to receive 2% (Group 1) or 4% lidocaine (Group 2) by a spray-as-you-go technique with the fiberoptic bronchoscope, in a double-blind manner. After airway topical anesthesia, awake fiberoptic orotracheal intubation (FOI) was performed. Level of sedation, time for each lidocaine spray in different targeted areas, total times for airway sprays, total dosages of lidocaine used for airway sprays, intubation times, and number of intubation attempts were noted. An independent investigator scored patients' comfort during airway topical anesthesia, patients' reaction, coughing severity, and intubating condition during awake FOI, and observed changes of arterial blood pressure and heart rate during each stage in the airway manipulation process. Serial blood samples were obtained for analysis of plasma lidocaine concentrations. Except for the total dosages and plasma concentrations of lidocaine, there were no significant differences in any of the observed variables between groups. All patients exhibited excellent or acceptable intubating conditions. The total dosages of lidocaine were significantly smaller in Group 1 (3.4 +/- 0.6 mg/kg) than in Group 2 (7.1 +/- 2.1 mg/kg). The plasma lidocaine concentrations in all observed points after the supraglottic sprays were larger in Group 2 than in Group 1. Both 2% and 4% lidocaine administered topically by a spray-as-you-go technique can provide clinically acceptable intubating conditions for awake FOI in sedated patients with a difficult airway. As compared with 4% lidocaine, however, 2% lidocaine requires a smaller dosage and results in lower plasma concentrations.

Fiberoptic Oral Intubation

Previous studies have indicated that fiberoptic orotracheal intubation (FOI) skills can be learned outside the operating room. The purpose of this study was to determine which of two educational interventions allows learners to gain greater capacity for performing the procedure. Respiratory therapists were randomly assigned to a low-fidelity or high-fidelity training model group. The low-fidelity group was guided by experts, on a nonanatomic model designed to refine fiberoptic manipulation skills. The high-fidelity group practiced their skills on a computerized virtual reality bronchoscopy simulator. After training, subjects performed two consecutive FOIs on healthy, anesthetized patients with predicted "easy" intubations. Each subject's FOI was evaluated by blinded examiners, using a validated global rating scale and checklist. Success and time were also measured. Data were analyzed using a two-way mixed design analysis of variance. There was no significant difference between the low-fidelity (n = 14) and high-fidelity (n = 14) model groups when compared with the global rating scale, checklist, time, and success at achieving tracheal intubation (all P = not significant). Second attempts in both groups were significantly better than first attempts (P < 0.001), and there was no interaction between "fidelity of training model" and "first versus second attempt" scores. There was no added benefit from training on a costly virtual reality model with respect to transfer of FOI skills to intraoperative patient care. Second attempts in both groups were significantly better than first attempts. Low-fidelity models for FOI training outside the operating room are an alternative for programs with budgetary constraints.

This Month in Anesthesiology

Mechanisms underlying the alleged cancer-promoting effects of blood transfusion are unknown, including the involvement of donors' leukocytes, erythrocytes, and soluble factors. Two tumor models were used in rats to study the impact of blood transfusion on the host ability to clear circulating cancer cells and host survival rates. The potential deleterious characteristics of the transfusion were also studied. Blood transfusion, in conjunction with blood storage time, was found to be an independent and significant risk factor for cancer progression, and aged erythrocytes mediated the effects. In rats, transfusion of fresh blood is less harmful than transfusion of stored blood. These results have implications for cancer patients receiving erythrocyte transfusions. See the accompanying Editorial View on page 951 This study examined the effect of isoflurane on γ-aminobutyric acid (GABA) levels in pontine reticular formation and the effect of drugs that increase or decrease GABA levels in the pontine reticular formation in experimental animals. Compared with wakefulness, GABA levels were significantly decreased by isoflurane. Nipecotic acid increased GABA levels and increased isoflurane induction time, whereas 3-mercaptopropionic acid decreased GABA levels and decreased isoflurane induction time. These results indicate that decreasing rather than increasing pontine reticular formation GABA levels is one mechanism by which isoflurane causes loss of consciousness and altered cortical excitability. See the accompanying Editorial View on page 948 Using a new risk scale developed for children, the effect size was calculated for treatments recommended for the pediatric population in the new Guidelines for the Management of Postoperative Nausea and Vomiting. Six single-drug therapies and five combination treatments were analyzed for risk reduction. With single-agent therapy using the 5-hydroxytryptamine receptor antagonists or dexamethasone, a 50–60% relative risk reduction is expected. Droperidol offers only a 40% decrease. With the combinations of a 5-hydroxytryptamine receptor antagonist and dexamethasone, a relative risk reduction in vomiting of about 80% is expected.In the senescent heart, β-adrenergic responsiveness is altered in parallel with β1- and β2-adrenoceptor down-regulation. This study tested the hypothesis that the β3-adrenoceptor plays a role in β-adrenergic receptor dysfunction in the senescent heart. β-adrenergic responses were investigated in vivo using echocardiography and in vitro using isolated left ventricular papillary muscle in young adult and senescent rats. An impaired positive inotropic effect in parallel with β3-adrenoceptor up-regulation was confirmed in senescent hearts both in vivo and in vitro . In the senescent group, the positive inotropic effect of β-adrenergic agonists was partially restored by nitric oxide synthase inhibitors. This was not the case in the young adult group. These results indicate β3-adrenoceptor overexpression plays a role in the altered β-adrenergic response in senescent cardiomyopathy via the induction of nitric oxide. See the accompanying Editorial View on page 956 Supervision of anesthesia residents by an attending anesthesiologist is associated with a decreased incidence of complications during emergent intubations outside the operating room. See the accompanying Editorial View on page 945 Training for fiberoptic orotracheal intubation using a high-fidelity simulator was not different than training with a low-fidelity simulator.Desmopressin is associated with a significant reduction in transfusion of blood products.This review evaluates different methods for determination of sympathetic nervous system activity and describes its role in human neurohumoral circulatory control. The effects of general anesthesia on sympathetic nervous system activity and their relevance for clinical anesthesia are discussed.

Optimal effect concentration of remifentanil in awake fiberoptic orotracheal intubation

Anaesthesia and Critical Care, School of Medicine. Universidad de Navarra, Pamplona, Navarra, Spain

Pain Management: Citizenship or Human Right?

1. Johnson DM, From AM, Smith RB, From RP, Maktabi MA. Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation. Anesthesiology 2005;102:910–14 2. Kihara S, Yaguchi Y, Taguchi N, Brimacombe JR, Watanabe S. The Styletscope is a better intubation tool than a conventional stylet during simulated cervical spine immobilization. Can J Anaesth 2005;52:105–10