Awake Intubation In Patient Research Articles

Can concurrent use of king vision video laryngoscope and fiberoptic bronchoscope improve efficacy and safety of awake intubation in patients with limited mouth opening? - A case report

Securing the airway by endotracheal intubation in a patient with a restrictive mouth opening poses a challenge to anesthesiologists. Awake tracheal intubation using flexible fiberoptic bronchoscopy is the gold standard in the anesthetic management of patients with restricted mouth openings. Awake video laryngoscopy (VL) is being increasingly used for the management of the anticipated difficult airways. We report a case of temporomandibular joint ankylosis with restrictive mouth opening posted for laparoscopic nephrectomy managed by awake intubation with the combined use of king vision VL (KVVL) and fiberoptic bronchoscope (FOB). KVVL provided an improved and clear view of the airway structures and FOB helped in guiding and maneuvering the tube safely into the larynx. The combined use of KVVL and FOB enhanced the effectiveness and safety of the procedure.

Anesthetic Management with Intubation in Awake Patient with Ludwig's Angina Using Dexmedetomidine and Ketamine: A Case Report

Introduction: Ludwig's Angina (LA) is a bacterial infection of the submandibular space that can cause airway obstruction. Prompt surgical treatment and antimicrobial therapy are crucial. Airway evaluation is important to identify risk factors for difficult intubation and anatomical distortion that may require awake endotracheal intubation. Case presentation: A 22-year-old female presented to the emergency department with left submandibular pain, edema, increased skin temperature, and erythema with a history of grade III caries of 6 months evolution without treatment. Physical examination revealed extension to the left lateral neck region and mild respiratory distress. Classified as ASA grade III, the patient underwent awake intubation using dexmedetomidine (DXM) and ketamine (KET), followed by balanced general anesthesia for the surgical procedure. Clinical discussion: The patient's condition predicted high difficult airway, therefore awake intubation was performed to maintain spontaneous ventilation and reduce cardiac arrest risk. In this case, DXM was used to avoid anxiety and respiratory depression, while KET was employed for its analgesic, bronchodilator, and tachycardic effects. Conclusion: Ketamine and dexmedetomidine allow adequate spontaneous ventilatory mechanics, without respiratory depressant effect. Further research is needed to find more anesthetic drugs that can be used for intubation without suppressing autonomic ventilation, and to develop guidelines to prevent respiratory depressant effects in patients with LA.

Strategies to achieve adherence to prone positioning in awake COVID-19 patients with high-flow nasal oxygen. A case series.

IntroductionThe use of high-flow nasal oxygen (HFNO) is a simple method that can reduce intubation in patients with hypoxemic acute respiratory failure (ARF). Early and prolonged prone position has demonstrated benefits on mortality in mechanically ventilated patients and on intubation in awake patients with ARF. However, strategies to achieve adherence to awake prone positioning (APP) have not been previously described.Case and outcomesWe present six patients with ARF due to COVID-19 treated with HFNO and APP. The median (p25–75) of PaFiO2 upon admission was 121 (112–175). The average duration of APP on the first day was 16 h (SD 5 h). Duration (median p25–75) in APP for the following 20 days was 13 (10–18) h/day. Several strategies such as the presence of a health care team, recreational activities, adaptation of the circadian rhythm, oral nutritional support, and analgesics were used to improve prone tolerance. None of the patients suffered from delirium, all were ambulating on discharge from the ICU and none require intubation.ConclusionThe case series presented show the feasibility of prolonged use of HFNO and APP in patients with COVID-19 and severe persistent hypoxemia and described strategies to enhance adherence.

Awake videolaryngoscopic orotracheal intubation in patients with laryngeal tumour using the C-MAC D-Blade.

ABSTRACTBackground and Aims:This study assessed the applicability of C-MAC videolaryngoscope (VL) D-blade for awake intubation in patients with laryngeal tumour. The primary study objective was to determine the rate of successful intubation in the first attempt. The other parameters recorded were number of attempts required for intubation, duration of different stages of intubation, haemodynamics, ease of intubation and patient comfort on visual analogue scale (VAS) postoperatively.Methods:Thirty patients were studied. Patients were sedated with dexmedetomidine and fentanyl as a slow bolus (over 20 min) and Ramsay sedation score was assessed. Topicalisation of the oropharynx, tonsillar pillars and base of the tongue was done with lignocaine 10% spray. Four ml of 4% lignocaine using MADgic atomiser was used for anaesthetising the glottis and the tracheal lumen.Results:Successful intubation was achieved in 86.6% patients in first attempt and 13.3% in two attempts. Total time for all intubations was less than 30 seconds. Fremantle score was F-1-C-MAC D-blade (easy intubation with full view) in 60% patients, while 23.3% had F-2-C-MAC D-blade (full view and either required more than one attempt or a modified technique), 13.3% had P-1-C-MAC D-blade (partial view with easy intubation) and 3.3% had P-2-C-MAC D-blade (partial view and required more than one attempt or a modified technique). The VAS score for anaesthesiologist’s ease and for patient’s experience was 85.83 ± 7.20 and 86.66 ± 14.46, respectively.Conclusion:C-MAC VL D-blade-assisted awake intubation is an effective and safe method to manage the airway of patients with laryngeal tumour once adequate topicalisation is ensured before the procedure.

Use of McGrath videolaryngoscope during awake intubation in patients undergoing surgery for cervical spine instability

Use of McGrath videolaryngoscope during awake intubation in patients undergoing surgery for cervical spine instability

Awake videolaryngoscopy versus fiberoptic bronchoscopy.

The difficult airway remains an ongoing concern in daily anesthesia practice, with awake intubation being an important component of its management. Classically, fiberoptic bronchoscope-assisted tracheal intubation was the method of choice in the awake patient. The development of new generation videolaryngoscopes has revolutionized the approach to tracheal intubation in the anesthetized patient. The question whether videolaryngoscopes have a place in the intubation of the difficult airway in the awake patient is currently being addressed. Randomized controlled trials and their meta-analysis have shown that videolaryngoscopes provide similar success rates and faster intubation times when compared with fiberoptic bronchoscope intubation in awake patients with difficult airways. Videolaryngoscopy is a valid technique that should be considered for difficult airway management in the awake patient.

Clinical Application of Upper Airways Topical Anesthesia in Endotracheal Intubation in Awake Patients of Giant Goiters

Clinical Application of Upper Airways Topical Anesthesia in Endotracheal Intubation in Awake Patients of Giant Goiters

The use of the C-MAC videolaryngoscope for awake intubation in patients with a predicted extremely difficult airway: case series.

The C-MAC videolaryngoscope was evaluated for intubation in patients with predicted extremely difficult airway. The presented cases are patients with neoplasm tumors in larynx. In all cases, awake intubation using C-MAC videolaryngoscope was performed in patients breathing spontaneously, under local anaesthesia, with oxygen administered via nasal catheter. All intubations were successful and uneventful. The pre-surgery examination (CT scans and fiberscope laryngeal examination) was compared with view of larynx obtained during laryngoscopy. Based on my experience, I assume that C-MAC videolaryngoscope is a very useful tool for anaesthesiologists and can be applied not only for unexpected difficult intubation but also for predicted difficult airway. Moreover, it could be used as an additional diagnosis tool before larynx surgery. The view obtained with the C-MAC videlaryngoscope corresponds with larynx examination performed before surgery, and could potentially reveal more details.

Awake tracheal intubation in anticipated difficult airways: LMA Fastrach vs flexible bronchoscope: A pilot study

Study objectiveTo compare the use of LMA Fastrach intubating laryngeal mask airway (ILMA) to flexible bronchoscopy (FB) for awake intubation in patients with difficult airways. DesignRandomized prospective study. SettingLarge academic medical center. PatientsForty adult patients, American Society of Anesthesiologists I-IV, meeting the criteria for awake intubation based on history and physical examination. InterventionsAfter sedation and airway topicalization, patients were randomized to either FB group, n=19, or ILMA group, n=21. All intubations were performed by or under the supervision of an attending anesthesiologists, with variable participation of residents or certified registered nurse anesthetists. A maximum of three attempts were permitted with the assigned technique, to be followed by the alternative method in case of failure. MeasurementsTimes to carbon dioxide (end-tidal carbon dioxide) detection, endotracheal tube placement, number of attempts, training level of operator, and adverse events were recorded. Blood pressure, oxygen saturation, and heart rate were measured. Patients were interviewed the following day regarding their experience and satisfaction. Main resultsOverall intubation success rate within three attempts was 95% for both groups. However, successful intubation on the first attempt occurred at a significantly higher rate with ILMA vs FB (95% vs 58%; P=.0028). Total mean time to endotracheal tube placement was also significantly shorter in the ILMA group vs FB (92 vs 246 seconds; P=.0001). There were no adverse events in either group, and patient satisfaction was not significantly different. ConclusionAwake intubation can be performed successfully and expeditiously with the use of LMA Fastrach in patients with a difficult airway and no contraindication to a blind technique. It compared favorably to the use of the fiberoptic bronchoscope in the patient cohort presented in this study.

Awake endotracheal intubation in patients with severely restricted mouth opening- alternative devices to fiberscope: series of cases and literature review

Abstract Awake Fiberoptic Intubation (AFI) is a standard method of airway management in the case of anticipated difficult intubation. It is usually performed with the use of flexible fiberscopes. In this report we have described two methods in which alternative devices to the fiberscope were utilized for awake intubation in patients with severely restricted mouth opening scheduled for craniomaxillofacial surgery: TruView PCD and Levitan FPS. Information about the use of these devices in such conditions has not been previously published in the literature. Some of the possible advantages of these alternative methods for AFI result from the fact that they are easy to use, especially for anesthesiologists who are relatively inexperienced with fiberscope intubation procedures. Additionally, these alternatives are cheaper than fiberscopes and can be used for many AFI procedures.

Gastric Tubes and Airway Management in Patients at Risk of Aspiration

Rapid sequence induction and intubation (RSII) and awake tracheal intubation are commonly used anesthetic techniques in patients at risk of pulmonary aspiration of gastric or esophageal contents. Some of these patients may have a gastric tube (GT) placed preoperatively. Currently, there are no guidelines regarding which patient should have a GT placed before anesthetic induction. Furthermore, clinicians are not in agreement as to whether to keep a GT in situ, or to partially or completely withdraw it before anesthetic induction. In this review we provide a historical perspective of the use of GTs during anesthetic induction in patients at risk of pulmonary aspiration. Before the introduction of cricoid pressure (CP) in 1961, various techniques were used including RSII combined with a head-up tilt. Sellick initially recommended the withdrawal of the GT before anesthetic induction. He hypothesized that a GT increases the risk of regurgitation and interferes with the compression of the upper esophagus during CP. He later modified his view and emphasized the safety of CP in the presence of a GT. Despite subsequent studies supporting the effectiveness of CP in occluding the esophagus around a GT, Sellick's early view has been perpetuated by investigators who recommend partial or complete withdrawal of the GT. On the basis of available information, we have formulated an algorithm for airway management in patients at risk of aspiration of gastric or esophageal contents. The approach in an individual patient depends on: the procedure; type and severity of the underlying pathology; state of consciousness; likelihood of difficult airway; whether or not the GT is in place; contraindications to the use of RSII or CP. The algorithm calls for the preanesthetic use of a large-bore GT to remove undigested food particles and awake intubation in patients with achalasia, and emptying the pouch by external pressure and avoidance of a GT in patients with Zenker diverticulum. It also stipulates that in patients with gastric distension without predictable airway difficulties, a clinical and imaging assessment will determine the need for a GT and in severe cases an attempt to insert a GT should be made. In the latter cases, the success of placement will indicate whether to use RSII or awake intubation. The GT should not be withdrawn and should be connected to suction during induction. Airway management and the use of GTs in the surgical correction of certain gastrointestinal anomalies in infants and children are discussed.

Comparative study between fibro-optic bronchoscope and rigid laryngoscope in direct laryngoscopy with microlaryngosurgery

ObjectiveAnesthesia of patient for direct laryngoscopy (DL) and microlaryngosurgery (MLS) was technically challenging. The anesthetist had usually concern about the loss of spontaneous ventilation and occurrence of obstruction after induction with IV drugs. The aim of this study was to compare between flexible fibro-optic bronchoscope and direct rigid laryngoscope during awake intubation in patients with laryngeal mass scheduled for direct laryngoscopic surgery (DL) and microlaryngosurgery (MLS). It was a study to assess the best way for intubation with the least side effects, discomfort to the patients and high success rate of intubation.MethodsFourty adult patients Malampati 1,2 and ASA I,II,III with small laryngeal mass or polyp scheduled for direct laryngoscope (DL) and microlaryngoscopic surgery. They were randomly computerized divided into two groups 20 patients in each group; Group FO; intubation with flexible fibro-optic bronchoscope. Group RL; intubation with rigid laryngoscope.ResultsThe time of intubation was statistically significantly higher in fibro-optic group (group FO) (92 ± 34 s) than rigid laryngoscope group (group RL) (35 ± 5 s). There were two patients in group RL needed 2nd intubation attempt for better visualization of the view but there were six patients in group FO needed 2nd intubation attempt for suction of secretion and blood. According to modified six point scale the patients ranged between 1 and 3 in group FO while they range between 2 and 4 in group RL.ConclusionThe study suggested that the flexible fibro-optic bronchoscope was very comfortable to the patients and less traumatic with less cardiovascular stress but it took longer time and had a higher incidence of 2nd attempt and failure rate. Accordingly, it recommend the use of flexible fibro-optic bronchoscope in expected small size and non-bloody mass with prepared rigid laryngoscope and tube with stylet to be ready to use if needed.

Sedation effect of dexmedetomidine on awake intubation in patients with difficult airway

Sedation effect of dexmedetomidine on awake intubation in patients with difficult airway

A new method for ultrasound-guided superior laryngeal nerve block

ObjectiveA block of the internal branch of the superior laryngeal nerve (ibSLN) is performed to facilitate awake intubation in patients with a difficult airway. The technique is usually done blindly using landmarks. We delineate a new method using ultrasound guidance while performing a superior laryngeal nerve block. Materials and MethodsAfter approval by the ethics committee and with permission from the involved families, six unembalmed fresh human cadavers were used for the study. In each cadaver, bilateral ibSLN blocks were performed using ultrasound guidance. The probe was placed longitudinally over the submandibular area to produce a sagittal view. After identification of the greater horn of the hyoid bone and thyroid cartilage, 2 mL methylene blue dye was injected using an out-of-plane method. Another anatomist dissected the tissue to determine if the nerve was bathed in the dye. ResultsAll except one of the 12 ibSLNs were bathed in the dye. Ultrasound-guided nerve block was successful in 11 of 12 ibSLN. ConclusionUltrasound may be an alternative method to identify the greater horn of the hyoid bone and thyroid cartilage as landmarks while performing an ibSLN block.

Reply

Editor, We sincerely thank Xue et al.1 for the careful reading of our article2 and their valuable comments. We recall that the primary purposes of this study were the feasibility of awake fibreoptic intubation and patient tolerability of this type of procedure. On the first point, we fully agree with the reservation of Xue et al. about hydroxyzine premedication which is no longer routinely used in our patients. As for midazolam, it had not seemed appropriate at the time of the study because of its deleterious effects on airway tone and on patients’ memory of the intubation (patients’ tolerability of the procedure was one of the points tested in the study). Because of the high variability of responses among patients and the depressant effect of the drug on the tone of airway muscles, we still reject its use for predicted difficult intubation in awake patients. Regarding the second point, we have also abandoned the routine use of atropine and scopolamine given as antisialagogue agents. However, most of the patients actually suffer from a lack of secretions due to previous cancer treatments (surgery, radiation therapy) and glycopyrrolate is not available for clinical use in France. Administration of atropine or scopolamine is sometimes required to diminish secretions and facilitate intubation. Information on the duration of upper airway preparation would certainly be helpful, but this point did not seem essential to us, as this preparation step can be performed outside the operating room, thereby avoiding delays in the turnover of patients. However, we agree that the quality of airway preparation is essential to the success of the procedure. Finally, we confirm that independent investigators evaluated patients’ perception and recall of the procedure. In total, 84–91% of our patients rated their global perception of awake intubation as good, even when the procedure did not meet all the criteria for success. We believe that this point should be distinguished from anaesthesia awareness, as this occurs when a patient under general anaesthesia becomes aware of events during invasive surgery, but without discomfort or pain. Indeed, patients in our study were fully informed of the procedure and of their potential reactions. They were in constant vocal contact with the operator and provided clear answers to the operator's questions until the end of the intubation and induction of general anaesthesia by propofol. They were fully aware beforehand of the necessity to maintain spontaneous breathing, even if the procedure carried a risk of transient discomfort. Almost all patients were willing to undergo the same procedure in the future if medically indicated.

Comparison among different dosages of dexmedetomidine combined with sufentanil for tracheal intubation in awake patients

Objeetive to compare the effect of different dosages of dexmedetomidine (DEX) combined with sufentanil for tracheal intubation in awake patients. Methods Ninety patients with Mallampati test Ⅲ-Ⅳ were randomly assigned into three groups (n=30).Group Ⅰ received intravenously pumping DEX 0.8 μg/kg plus sufentanil 0.1 μg/kg,group Ⅱ with DEX 1.0 μg/kg plus sufentanil 0.1 μg/kg,group Ⅲwith DEX 1.2 μg/kg plus sufentanil 0.1 μg/kg.mean arterial pressure (MAP),heart rate(HR),oxygen saturation (SpO2) of patients were recorded at the time points of entering the operationroom (T0),before intubation (T1) and intubation (T2),respectively.Serial blood samples were obtained for analysis of plasma cortisol concentrations at each time points.The responses at the intubation,and Ramsay scores before intubation were recored.Memory of intubation was inquired after operation. Results HR in patients of group Ⅱ at T1(68±9) beats/min were significantly decreased compared with that at T0(78±10)beats/min (P＜0.05),HR inpatients of group Ⅲ at T1 (68±17) beats/min and T2 (64±6) beats/min are significantly decreased compared with that at T0(81±12) beats/min(P＜0.05).HR in patients of group Ⅱ (68±9) beats/min and Ⅲ (68±17) beats/min at T1 are significantly decreased compared with that of group Ⅰ (81±12) beats/nin(P~05) and HR in patients of group Ⅲ at T2(64±6) beats/min are significantly decreased compared with that of group Ⅰ (85±15) beats/min(P＜0.01).MAP in patients of group Ⅲ at T2(111±-9) mm Hg (1 mm Hg=0.133 kPa) are significantly increased compared with that at T0(98±10) mm Hg(P＜0.05 ).MAP in patients of group Ⅱ and Ⅲ at T1 and T2 are significantly increased compared with that of group Ⅰ (P＜0.05).Ramsay score in patients of group Ⅱ and Ⅱ at the moment of intubation are significantly higher than that in patients of group Ⅰ (P＜0.05). Conclusions These results show that it is optimal for 1.0 μg/kg DEX combined 0.1 μg/kg sufentanil used for awake intubation. Key words: Dexmedetomidine; Sufentanil; Intubation,intratracheal

Fiberoptic nasotracheal intubation in awake patient with severe ankylosing spondilitis: a case report

Fiberoptic nasotracheal intubation in awake patient with severe ankylosing spondilitis: a case report

Evaluation of the Bonfils intubating fibrescope for predicted difficult intubation in awake patients with ear, nose and throat cancer

Anaesthesiologists are regularly faced with difficult tracheal intubation. The objective of the study was to evaluate the feasibility and tolerability of tracheal intubation with the Bonfils intubating fibrescope in awake adult patients with predicted difficult intubation undergoing cancer surgery in an ear, nose and throat unit. Intubation was performed under local anaesthesia and remifentanil sedation with spontaneous ventilation. The primary endpoint was the proportion of intubations which met the following quality requirements: successful intubation (≤ 2 attempts and duration <180 s) and good tolerability (Fahey scale <2). Secondary endpoints included the operational problems encountered and patients' perception of the procedure immediately and 7 days after the intervention. Using a one-stage Fleming design, 32 patients were required to complete the study. Forty-one eligible adult patients were enrolled. Between February 2008 and March 2009, the primary endpoint could be evaluated in 33 patients. Quality requirements were met in 26 patients (78.8%) and not met in seven patients (five were intubated with the Bonfils fibrescope and two using another technique). Difficulties were reported in 13 patients (39.4%). Eighty-four percent of the patients had a good or very good perception of the intubation shortly after the procedure, and 91% after 7 days. Tracheal intubation using the Bonfils intubating fibrescope was successful in almost all patients (93.9%). The 78.8% incidence of interventions which met the quality requirements is high in the context of ear, nose and throat cancer and acceptable in current clinical practice. In ear, nose and throat cancer patients who do not require nasopharyngeal intubation and in whom orotracheal intubation is predicted to be difficult, the use of the Bonfils intubating fibrescope is safe, effective and well tolerated. NCT01070537, URL: http://clinicaltrials.gov/ct2/show/NCT01070537?term=bonfils&rank=2.

A reply

We would like to thank Drs Belagodu and Kessell for their comments. We agree that our patient selection criteria probably over-identified difficult intubations. Previous difficult intubation has a better positive predictive value (69–78%) than other independent predictive factors. It means that two to three of the nine patients included in the study could not have been really difficult to intubate. We routinely use the Arné Score that has been accepted by our local Society (Societat Catalana d’Anestesiologia, Reanimació i Terapeùtica del dolor, SCARTD) [1]. This test explores difficult intubation (defined as the need for special techniques additional to Macintosh laryngoscopy to intubate the trachea), instead of difficult laryngoscopy alone. It has a better likelihood ratio than Wilson or El Ganzouri tests. Patients with an Arné score ≥ 11, compared to El Ganzouri score ≥ 4 or Wilson score ≥ 4, have the highest probability of being difficult to intubate when the test is positive. The El Ganzouri simplified test has a specifity of 93.8% and sensitivity 64.5% for predicting difficult laryngoscopy in general surgery patients, that is a likelihood ratio of 11 and a probability of a difficult laryngoscopy when the test is positive of around 21%. The Arné test has a 94% specificity and 96% sensitivity for predicting difficult intubation, that is a likelihood ratio of 16 and a probability of a difficult intubation when the test is positive around 25%. The combination of remifentanil, midazolam and topical anaesthesia caused loss of muscle tone and mild airway obstruction in some patients while unstimulated, which may explain the low oxygen saturation before starting the procedure. Respiratory rate was kept above 8 breaths.min−1 by maintaining verbal contact and adjusting the remifentanil infusion. The patients were interviewed the following day after by the authors, which may be an important bias. However, awake intubation requires a climate of confidence and good communication with the patient. We constantly encourage patients to report any discomfort or unpleasant feelings. As patients are concerned about future intubation, we think they would not hesitate to report unpleasant recall. When deciding whether or not to perform awake intubation in patients with low positive scores of difficult intubation prediction, we also take into account further relevant information for patient safety, such as the predicted difficult mask ventilation score [2]. For that reason, we considered the term ‘difficult airway’ more appropriate than ‘difficult intubation’ for the study title.

Awake tracheal intubation using the Airtraq® laryngoscope: a case series

The Airtraq laryngoscope (AL) is a new single use indirect laryngoscope designed to facilitate tracheal intubation in anaesthetised patients either with normal or difficult airway anatomy. It is designed to provide a view of the glottis without alignment of the oral, pharyngeal and tracheal axes. We report four cases of successful awake tracheal intubation using the AL. The first case is a patient with severe ankylosing spondylitis and the other three cases with anticipated difficult airway. An awake intubation under sedation and topical airway anaesthesia was chosen. We consider that the AL can be used effectively to accomplish an awake intubation in patients with a suspected or known difficult airway and may be a useful alternative where other methods for awake intubation have failed or are not available.