Flexible Fiberoptic Intubation Research Articles

Institution of a difficult airway response team for emergency department patients with anticipated or encountered difficult airways: Descriptive analysis of a 5-year experience at an academic teaching hospital.

This study aimed to describe characteristics and outcomes associated with difficult airway response team (DART) encounters in the emergency department (ED). We performed a descriptive analysis of a prospective, single-center database of DART encounters in the ED from April 1, 2016 to March 31, 2021 cross-referenced with retrospective chart review. Adult ED patients ≥18 years old for whom a DART was activated were eligible. We prospectively collected activation characteristics, intubation indications, operator characteristics, and intubation methods used for DART encounters. Retrospective chart review was conducted to obtain patient demographics and outcome variables. Descriptive analyses were computed for all outcomes. We analyzed 89 DART encounters. No intubation attempts were made prior to DART activation in 52 cases (58.4%). The most common indications for intubation were angioedema (n=17, 19.1%) or other airway obstruction (n=15, 16.9%). A definitive airway was established by anesthesiology (n=46, 51.7%), emergency medicine (n=25, 28.1%), trauma surgery (n=9, 10.1%), and ENT (n=5, 5.6%). The most common method of intubation used to establish a definitive airway was video laryngoscopy with a bougie or D-blade (n=29, 32.6%) followed by flexible fiberoptic intubation (n=19, 21.3%). A surgical airway was required in eight encounters (cricothyrotomy [n=4, 4.5%]; tracheostomy [n=4, 4.5%]). Cases were managed in the ED (n=73, 82%), operating room (OR) (n=10, 11.2%), and intensive care unit (ICU) (n=1, 1.1%). All patients requiring intubation had an endotracheal or surgical airway established. Our findings provide important insights regarding ED DART utilization and have implications when considering institution of a DART in the ED.

Anesthetic management in a child with Coffin Siris syndrome.

Dear Editor, An 8-year-old boy with ARID1B-CSS Coffin Siris Syndrome (CSS) presented with left inguinal hernia for herniotomy. The child had an uneventful neonatal period but developed recurrent upper respiratory tract infection at 2 months of age requiring frequent hospitalization. He also developed an intellectual disability, hyperactivity, and seizure disorder. Evaluated as a floppy infant, genetic workup revealed ARID1B and SOX11 gene mutation associated with CSS. He had a hypoplastic fifth finger in his hands, bushy eyebrows, everted lips, coarse facies, hypertrichosis, hypotonia, micrognathia, macroglossia, and high arched palate [Figure 1].Figure 1: (a) Note bushy eyebrows, coarse facies, hypertrichosis, everted lips, macroglossia, low anterior hairline, prominent ears (b) Hypoplastic fifth finger (c) Airway secured with Size 2 i-GelOn examination, the child was anxious, aggressive, and distracted. He was premedicated with oral midazolam 30 min prior and induced with sevoflurane. After achieving end-tidal concentration of 2.5%, iv cannula was placed and airway secured with size-2 i-Gel. The patient was maintained with sevoflurane at MAC 1-1.2 and pressure support ventilation (PSV-Pro, GE Datex Ohmeda, Aspire View). No opioids or muscle relaxant was used. Ultrasound-guided ilioinguinal and iliohypogastric nerve block (IIN/IHN) was given. At the end of the surgery, i-Gel was removed deep after ascertaining adequacy of ventilation. The patient was observed for 24 h before discharge. CSS (OMIM 135900), first described by Coffin GS, is a rare genetic condition caused by mutations in the ARID1B gene with a prevalence of <1:100000 and equal male-female preponderance.[1,2] Known as “fifth digit syndrome,” CSS is characterized by moderate to severe intellectual disability, absent or hypoplastic terminal phalanx of the fifth digit, craniofacial abnormalities, coarse facies, hypertrichosis, hypotonia, short neck, irregular and protruding teeth, wide nose with low nasal bridge, macroglossia, micrognathia, and high arched palate.[2] These features lead to feeding difficulties, recurrent respiratory tract infections during infancy owing to micro-aspirations, and pose a risk of transient apnea/laryngospasm in the perioperative period. Combined with facial dysmorphism, these factors present a difficult airway scenario. Awake flexible fiber-optic intubation is the best approach but possible in compliant patients only. In our case, the child was uncooperative and aggressive due to mental retardation, and the surgery did not necessitate tracheal intubation. Therefore, we used supra-glottic airway (i-Gel) while preserving spontaneous respiration. Numerous case reports have described the genotypic and phenotypic profile of CSS; however, few have described anesthetic management of patients with CSS, the details of which are mentioned in Table 1.[3–5] Spinal abnormalities such as spina bifida, scoliosis, etc., have been associated with CSS. Although no such abnormalities were found in our patient, we did not contemplate neuraxial block in our patient as IIN/IHN has proven to be equal or more efficacious and safer than caudal/central neuraxial block. Moreover, opioid-free anesthesia led to a faster and smoother recovery.Table 1: Airway management Techniques reported in patients with CSSCSS is a rare congenital syndrome with distinct craniofacial anomalies and mental retardation presenting a challenging scenario to the anesthesiologist in the perioperative period. Detailed insight of the child’s condition, thorough preoperative workup, and difficult airway preparedness are essential. Supra-glottic airway device presents an important tool in the armamentarium of anesthesiologist and a viable and easy alternative to flexible fiber-optic intubation for successful management of such cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Comparison of three video-assisted intubation methods: Rigid telescopes, C-MAC, flexible fiberoptic bronchoscopy, for anticipated difficult airways

ObjectiveThe aim of this study was to compare the efficiency and reliability of rigid telescopes with the two most used video-assisted intubation techniques. The primary outcome of the study is the first attempt orotracheal intubation success rate and the secondary outcomes include intubation time, mucosal injury, and complications during intubation. Materials and methodsAll patients that were predicted to have difficult intubation were prepared according to the video-assisted intubation technique and were randomly divided into three groups: Group 1 (REI group; n = 49) included patients that were intubated using rigid endoscope-assisted orotracheal intubation (REI) (0°, 45°, and 70°), 18-cm rigid telescope, full-HD camera, and Macintosh blade. Group 2 (V-MAC Group; n = 51) included patients that underwent tracheal intubation using a videolaryngoscope Macintosh (V-MAC). Group 3 (FFEI group; n = 53) included patients that underwent flexible fiberoptic tracheal intubation. Groups were compared with regard to intubation success rate, intubation time, number of intubation attempts, and intubation-related complications. ResultsThe study included a total of 153 patients aged 18–60 years who were predicted to have difficult intubation and underwent intubation with phonomicrosurgery and general anesthesia under elective conditions. Demographic and airway findings of the groups were similar, and no significant difference was found among the groups with regard to the number of intubation attempts (p > 0.05). Intubation was successful at the first attempt in 110 (72%), at the second attempt in 26 (17%), and at the third attempt in 17 (11%) patients. No significant difference was found among the three groups with regard to the number of intubation attempts (p > 0.05). Intubation time was significantly longer in the FFEI group compared to the other two groups (p < 0.05). The prevalence of mucosal injury to vocal cords was significantly lower in the REI group compared to other groups (p < 0.05). ConclusionRigid telescopes can be considered in elective surgeries of patients predicted to have difficult airway since they allow for rapid assessment of the airway, minimal mucosal damage, and rapid intubation.

A PROSPECTIVE RANDOMIZED STUDY TO EVALUATE THE ANALGESIC AND SEDATIVE EFFECTS OF FENTANYL AND MIDAZOLAM TO NALBUPHINE AND MIDAZOLAM IN PATIENTS UNDERGOING AWAKE FIBEROPTIC

Background- Awake nasal or oral flexible fiberoptic intubation (AFOI) is technique of choice in known or anticipated difficult airway . The main aim was to have calm and cooperative patient who can follow verbal commands while maintaining adequate oxygenation . In our study, we compared the analgesic and sedative effects of fentanyl and midazolam with nalbuphine and midazolam in patients undergoing awake fiberoptic intubationmore tolerable and comfortable for the patient but also to ensure optimal intubating conditions. Material and Methods– A prospective, randomized comparison study among patients between the age of 18 and 60yrs of either sex, with anticipated difficult airway . We compared the analgesic and sedative effects of fentanyl and midazolam with nalbuphine and midazolam in patients undergoing awake fiberoptic intubation. The primary objectives of our study were to observe the level of sedation, intubation score and OAS score after completion of procedure. The secondary objectives included assessment of patient comfort, intubation time, hemodynamic changes and complications. Results – We found that comfort score and intubation time were significant lesser in Group which received fentanyl and midazolam than Group which received nalbuphine and midazolam . (p&lt;0.05). The intubation attempt was similar in both groups (P&gt;0.05). Conclusion– we concluded that both regimens used in this study provided comparable intubating conditions, better sedation and analgesia was observed in group fentanyl for airway procedure events. Our study concluded fentanyl to be the drug of choice for blunting of pressor response in such patients.

Optical Devices in Tracheal Intubation-State of the Art in 2020.

The review article is focused on developments in optical devices, other than laryngoscopes, in airway management and tracheal intubation. It brings information on advantages and limitations in their use, compares different devices, and summarizes benefits in various clinical settings. Supraglottic airway devices may be used as a conduit for fiberscope-guided tracheal intubation mainly as a rescue plan in the scenario of difficult or failed laryngoscopy. Some of these devices offer the possibility of direct endotracheal tube placement. Hybrid devices combine the features of two different intubating tools. Rigid and semi-rigid optical stylets represent another option in airway management. They offer benefits in restricted mouth opening and may be used also for retromolar intubation. Awake flexible fiberoptic intubation has been a gold standard in predicted difficult laryngoscopy for decades. Modern flexible bronchoscopes used in anesthesia and intensive care are disposable devices and contain optical lenses instead of fibers. Endotracheal tubes with an incorporated optics are used mainly in thoracic anesthesia for lung separation. They are available in double-lumen and single-lumen versions. They offer a benefit of direct view to the carina and do not require flexible fiberscope for their correct placement.

Rigid Video Laryngoscopy for Intubation in Severe Pierre Robin Sequence: A Retrospective Review.

The anatomy of children with severe Pierre Robin sequence can present a challenge for direct laryngoscopy and intubation. Advanced techniques including flexible fiberoptic laryngoscopic intubation have been described but require highly specialized skill and equipment. Rigid video laryngoscopy is more accessible but has not been described in this population. Retrospective cohort study. A retrospective review was completed at a tertiary care center of all children between January 2016 and March 2020 with Pierre Robin sequence who underwent a mandibular distraction osteogenesis procedure. Intubation events were collected, and a descriptive analysis was performed. A univariate logistic regression model was applied to direct laryngoscopy and flexible fiberoptic laryngoscopy with rigid video laryngoscopy as a reference. Twenty-five patients were identified with a total of 56 endotracheal events. All patients were successfully intubated. Direct laryngoscopy was successful at first intubation attempt in 47.3% (9/19) of events. Six direct laryngoscopy events required switching to another device. Rigid video laryngoscopy was successful at first intubation attempt in 80.5% (29/36) of events. Two cases required switching to another device. Flexible fiberoptic laryngoscopy was found successful at first intubation attempt in 88.9% (8/9) of events. Direct laryngoscopy was 4 times more likely to fail first intubation attempt when compared to rigid video laryngoscopy (P < .05). There was no significant difference between rigid video laryngoscopy and flexible fiberoptic laryngoscopy for intubation. For children with Pierre Robin sequence rigid video laryngoscopy should be considered as a first attempt intubation device both in the operating room and for emergent situations. 4 Laryngoscope, 131:1647-1651, 2021.

Direct laryngoscopy assisted fiberoptic intubation: A novel technique for the pediatric airway

ObjectiveTo introduce a novel intubation technique for difficult pediatric airways. MethodsThis two-provider technique requires a direct laryngoscope and a flexible fiberoptic laryngoscope. One provider performs direct laryngoscopy which allows for introduction of the flexible laryngoscope. The second provider inserts the flexible laryngoscope with the endotracheal tube loaded, through the oropharynx in to the subglottis. ResultsWe report three pediatric patients that were initially unable to be intubated by conventional methods. We were ultimately able to successfully intubate these patients with difficult airways using our novel technique. ConclusionsWe found that this technique of direct laryngoscopy assisted flexible fiberoptic intubation is a useful adjunct in select pediatric difficult airway patients.

A Multidisciplinary Basic Airway Skills Boot Camp for Novice Trainees.

Introduction: Otolaryngology and anesthesiology residents may be the first responders to airway emergencies, even in the first weeks of training. These residents may be unfamiliar with the armamentarium of airway maneuvers, the most basic of which may be lifesaving. Boot camp education has been demonstrated to be effective in multiple disciplines. In this study, we examine whether an immersive, multidisciplinary boot camp style simulation course leads to an improvement in novice airway provider confidence.Methods: Novice otolaryngology and anesthesiology residents participated in an annual (2013-2018) multidisciplinary boot camp simulation course. Residents completed an anonymous pre- and post-test self-assessment tool reporting their confidence for airway skills and concepts from the curriculum. Responses were on a Likert scale from 1 to 5 (1=no familiarity, 5=extremely comfortable). We analyzed pre- and post-course participant self-reported comfort level with the airway management skills and concepts addressed in the course. Frequencies and percentages were reported. Fisher’s exact test was used to assess statistical significance at level 0.05.Results: A total of 62 residents, including 50 anesthesiology residents and 12 otolaryngology residents, completed a post-test self-assessment tool. For all topics covered in the course, there was a statistically significant change in the percentage of residents who reported familiarity with the topic (p<0.001). This corresponded to an increase in self-reported comfort level and a decrease in non-familiarity or discomfort with the airway topics covered in the course. The greatest increase in percentage of residents reporting feeling comfortable or extremely comfortable with the task after completion of the simulation boot camp were all moderately advanced airway maneuvers (laryngeal mask airway [LMA] placement, flexible fiberoptic intubation, glidescope intubation, endotracheal intubation, and two-person mask ventilation). The greatest decrease in non-familiarity or discomfort was seen in moderately complex to advanced airway topics (fiberoptic intubation, glidescope intubation, intubating LMA, rigid bronchoscopy, cricothyroidotomy, tracheostomy, and laryngectomy).Conclusions: Our data support the use of immersive surgical boot camp experiences to enhance resident familiarity and comfort and decrease unfamiliarity and discomfort with a wide variety of airway topics and maneuvers.

Anesthetic challenges in a large multinodular thyroidectomy at a peripheral hospital

We present a case of large multinodular goiter with retrosternal extension scheduled for thyroidectomy under general anesthesia (GA). We anticipated difficult airway due to tracheal compression as well as perioperative hemodynamic instability. She had had hyperthyroidism previously, which had been treated successfully. We planned and prepared to encounter airway problems in the light of Difficult Airway Society guidelines. After counselling and consent, her upper airways were sprayed with local anesthetic solution. Awake, flexible fiberoptic nasal intubation was performed and GA was induced. She had two episodes of bradycardia and hypotension peri-operatively, which were treated with inj atropine. Tracheostomy was performed in anticipation of tracheomalacia, which was de-cannulated on 3rd postoperative day. She was discharged on 4th post-operative day.Citation: Ikram M, Mahboob S. Anesthetic challenges in a large multinodular thyroidectomy at a peripheral hospital. Anaesth pain &amp; intensive care 2019;23(3):311- 313

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.

Dexmedetomidine nebulization as adjuvant to lignocaine during awake flexible fiberoptic intubation

Sir, Awake fiberoptic intubation (AFOI) is recommended for patients with anticipated difficult airway, failed intubation, and unstable cervical spine injury where optimum positioning for laryngoscopy is difficult to achieve. Preparation includes obtundation of airway reflexes, adequate sedation, and anxiolysis along with preservation patent airway and adequate ventilation. Dexmedetomidine produces hypnosis, amnesia, analgesia, anxiolysis, sympatholysis, and antisialogogue effects; all of them are desired during AFOI.[1] Administration of dexmedetomidine through inhalational route could be a new promising noninvasive method. The bioavailability of dexmedetomidine is 65% and 82% through nasal and buccal mucosa, respectively, following nebulization.[2] Here, we reported a series of four cases of patients with difficult airway in which dexmedetomidine was used as adjuvant to lignocaine nebulization before awake fiberoptic bronchoscope-guided nasotracheal intubation. Written consent was taken from all patients. All these patients were scheduled for mandibular excision and reconstruction under general anesthesia. After shifting the patients to operating room, standard ASA monitor was connected and baseline was taken. Injection glycopyrrolate 0.2 mg i.m., intranasal xylometazoline 0.1%, was given 15 min prior to nebulization to each patient. Patients were nebulized with mixture of 4% lignocaine 10 ml and dexmedetomidine 1 μg/kg by using ultrasonic nebulizer for 15 min followed by fiberoptic bronchoscope-guided nasotracheal intubation. All patients received supplemental oxygen (2 l/min) through the working channel of the bronchoscope. Following intubation, general anesthesia was induced. The parameters observed include heart rate, mean arterial pressure, oxygen saturation at 0, 5, 10, 15 (end of nebulization), and 20 min (just after intubation). Other parameters were observed such as cough and gag reflexes [severity graded as no cough, slight ≤2 coughs, moderate (3–5 coughs), severe (>5 coughs)], patient comfort (cooperative, restless/minimal resistance, severe resistance/requirement for immediate general anesthesia), and signs of lignocaine toxicity. Discussion There were bradycardia and hypotension noted during nebulization in case 2 and 3 as shown in Table 1. Tachycardia was noted at 20 min in case 2 and 4. One episode of cough and gag reflex was noted in case 2. No cough, gag, and other adverse effects such as bronchospasm, seizures due to lignocaine toxicity, and oversedation were recorded in rest of cases as shown in Table 1. Patients were comfortable throughout the procedure.Table 1: Shows vitals parameter and cough/gag reflexes during intubationBrummett et al.[3] studied the effect after perineural dexmedetomidine injection and they attributed to the increased duration of analgesia to the local action of dexmedetomidine. The analgesic effect of dexmedetomidine was not reversed by a ∞2-adrenoceptor antagonist (prazosin or idazoxan), hence confirming its local site of action. Hence, we hypothesize that dexmedetomidine nebulization provides surface analgesia to airway mucosa in addition to its systemic effect due to its effects on peripheral nerve endings. We could not measure systemic levels of the drugs due to lack of this facility in our institute. Hence, we limited the maximum dose of lignocaine to 400 mg and dexmedetomidine 1 μg/kg. For validation of our hypothesis, we further require randomized controlled studies. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Flexible Fiberoptic Intubation Is Rarely Used in Adult ED Patients

For difficult intubations, especially in patients with oral airway obstruction (e.g., from angioedema), flexible fiberoptic intubation (FFI) may be the

Suicidal hanging patient with complete tracheal rupture

In attempted suicide, laryngotracheal rupture caused by hanging leads to rapid death at the scene or before arrival at hospital. The case presented here describes a patient with complete tracheal rupture from an attempted suicidal hanging who was successfully resuscitated. Pre-hospital providers transferred the patient to hospital without being aware of the possibility of airway damage. Cardiac arrest occurred shortly after arrival at hospital. During the cardiopulmonary resuscitation, endotracheal intubation was performed, and fortunately, the tracheal tube was located just below the ruptured trachea and thus enabled ventilation. For patients suspected of having airway damage at the pre-hospital stage, awareness of the patient’s condition and adequate airway management are important. The management of laryngotracheal rupture which suggests that for patients not adequately ventilated, immediate treatment with flexible fiberoptic intubation or tracheostomy is needed to secure the airway. Equipment and personnel at the receiving hospital need to be prepared for immediate treatment.

Flexible Fiberoptic Intubation in Difficult Airway: A Retrospective Evaluation in a Portuguese University Hospital

Flexible Fiberoptic Intubation in Difficult Airway: A Retrospective Evaluation in a Portuguese University Hospital

Awake intubation by intubating laryngeal mask airway as an alternative to failed fiberoptic intubation: a case report

Fiberoptic intubation is sometimes very challenging in patients with head and neck cancer. It becomes much more difficult in postradiation period. There are few reported cases of awake intubation through intubating laryngeal mask airway after failure of fiberoptic method. We are presenting a case report of failed flexible fiberoptic intubation that was finally succeeded with intubating laryngeal mask airway while keeping the patient awake.

Comparison of Intubating Conditions using Fentanyl plus Propofol Versus Fentanyl plus Midazolam during Fiberoptic Laryngoscopy.

Awake nasal or oral flexible fiberoptic intubation is the airway management technique of choice in known or anticipated difficult airway, unstable cervical fracture, limited mouth opening (as in temporomandibular joint disease), mandibular-maxillary fixation and severe facial burns. Both optimal intubating condition and patient comfort are important for fiberoptic intubation. Optimal intubating conditions provided by an ideal sedation regimen would ensure haemodynamic stability, patient comfort, attenuation of airway reflexes and amnesia. To compare the intubating conditions using fentanyl plus propofol versus fentanyl plus midazolam during fiberoptic laryngoscopy. A prospective, comparative and randomized study was conducted on 60 patients of either gender aged between 18 and 60 years belonging to the American Society of Anaesthesiologists (ASA) grade-I or II scheduled for elective surgery. Patients were randomly allocated into two groups of 30 each. In group I, patients received i.v. fentanyl 1 μg/kg+ propofol 1 mg/kg to achieve an adequate level of sedation that is Ramsay Sedation Scale (RSS) score of 3. In group II, patients received i.v. fentanyl 1 μg/kg + midazolam 0.03 mg/kg to achieve RSS= score of 3. Haemodynamic parameters (heart rate, systolic and diastolic blood pressure, mean arterial pressure), SpO2, EtCO2, total comfort scale values and patient's tolerance were assessed during preoxygenation, fiberscope insertion and endotracheal intubation. Fentanyl plus midazolam group showed better patient comfort and maintenance of oxygen saturation than fentanyl plus propofol group during fiberoptic intubation. Both fentanyl plus midazolam and fentanyl plus propofol regimes are suitable for fiberoptic intubation. Fentanyl plus midazolam appeared to offer better tolerance, preservation of an airway and spontaneous ventilation, while maintaining haemodynamic stability.

Pediatric Blunt Neck Trauma Causing Esophageal and Complete Tracheal Transection

ABSTRACTBackground: Blunt injuries to the cervical trachea remain rare but present unique and challenging clinical scenarios for prehospital providers. These injuries depend on prehospital providers either definitively securing the injured airway or bridging the patient to a treatment facility that can mobilize the necessary resources. Case Summary: The case presented here involves a clothesline injury to a pediatric patient that resulted in complete tracheal transection and partial esophageal transection. Ground and air prehospital providers utilized a stepwise approach to this airway injury and achieved a favorable outcome. The patient was serendipitously intubated through a blind nasal approach that entered the proximal esophagus, exited through the tear and entered the distal trachea. Discussion: There is a paucity of literature describing the successful management of these devastating injuries. While some authors have advocated for early flexible fiberoptic intubation or proceeding directly to tracheostomy, these techniques are not available in the prehospital environment. This case also highlights the inherent issues with proceeding to cricothyroidotomy in patients with tracheal trauma and should give all providers pause before considering this management technique. Conclusion: Ultimately, a systematic approach to all airways will ensure that prehospital providers are best prepared for even the most challenging scenarios.

Chronic stridor in a nine-month-old—Consider esophageal foreign body

Abstract We present the case of a 9-month-old female with seven weeks of stridor. Initial lateral neck radiograph showed widening of the retropharyngeal space with significant mass effect displacing the cervical and thoracic trachea. She was taken emergently by ENT to the operating room for intubation. In the OR, flexible fiberoptic nasotracheal intubation was achieved. Through multimodality imaging and several procedures, she was found to have ingested part of a Christmas ornament, which lodged in the esophagus, causing a perforation with retropharyngeal phlegmon. This compressed the airway, causing respiratory distress. She improved on intravenous antibiotics and the ornament was retrieved endoscopically.

The efficacy of combined regional nerve blocks in awake orotracheal fiberoptic intubation.

Aims of Study:To evaluate the efficacy, hemodynamic changes, and patient comfort during awake fiberoptic intubation done under combined regional blocks.Materials and Methods:In the present observational study, 50 patients of American Society of Anesthesiologists ( ASA) Grade I–II, Mallampati Grade I–IV were given nerve blocks - bilateral glossopharyngeal nerve block, bilateral superior laryngeal nerve block, and recurrent laryngeal nerve block before awake fiberoptic intubation using 2% lidocaine.Results:Procedure was associated with minimal increases in hemodynamic parameters during the procedure and until 3 min after it. Most of the intubations were being carried out within 3 min. Patient comfort was satisfactory with 90% of patients having favorable grades.Discussion:The most common cause of mortality and serious morbidity due to anesthesia is from airway problems. One-third of all anesthetic deaths are due to failure to intubate and ventilate. Awake flexible fiberoptic intubation under local anesthesia is now an accepted technique for managing such situations. In awake patient's anatomy, muscle tone, airway protection, and ventilation are preserved, but it is essential to sufficiently anesthetize the upper airway before the performance of awake fiberoptic bronchoscope-guided intubation to ensure patient comfort and cooperation for which in our study we used the nerve block technique.Conclusion:A properly performed technique of awake fiberoptic intubation done under combined regional nerve blocks provides good intubating conditions, patient comfort and safety and results in minimal hemodynamic changes.

The Jaw Thrust Finds a Purpose During Flexible Fiberoptic Intubation

An unobstructed path through the airway makes fiberoptic intubation easier to perform. Patient positioning, airway adjuncts, and jaw or tongue manipulation have all been used to improve patency. The effect of the jaw thrust maneuver on airway obstruction in different patient positions has not been well studied. Researchers randomly …