Fiberoptic Nasotracheal Intubation Research Articles

Conversion of orotracheal to nasotracheal intubation using a fiberoptic bronchoscope in a patient with intraoral hematoma

Conversion of orotracheal to nasotracheal intubation using a fiberoptic bronchoscope in a patient with intraoral hematoma

Dexmedetomidine versus remifentanil sedation during awake fiberoptic nasotracheal intubation: a double-blinded randomized controlled trial

Awake fiberoptic nasotracheal intubation is usually performed in patients with an anticipated difficult airway. This study compares dexmedetomidine and remifentanil for conscious sedation during fiberoptic intubation. Forty patients undergoing elective awake fiberoptic nasotracheal intubation were allocated randomly to receive either dexmedetomidine (n=20) or remifentanil (n=20). Primary outcome measures were endoscopy, intubation, and post-intubation conditions as scored by the attending anesthesiologist. Other parameters included the time taken to achieve the desired level of sedation, endoscopy time, intubation time, and hemodynamic changes during the procedure. An interview was conducted 24h after surgery to evaluate patients' recall of and satisfaction with the procedure. The median [interquartile range] endoscopy score (graded 0-5) in the dexmedetomidine group (2 [1-2]) was significantly better than in patients who received remifentanil (3 [2-3]; p<0.01). Recall of intubation was significantly lower in the dexmedetomidine group (p=0.027). Dexmedetomidine provided better patient satisfaction than remifentanil (2 [1-2] and 2 [2-3], respectively; p=0.022). Patients in the dexmedetomidine group had fewer heart rate responses during endoscopy and intubation as compared to the remifentanil group (p<0.001 and p=0.004, respectively). Peripheral oxygen saturation was less in the remifentanil group during endoscopy (p=0.003). There were no significant differences in intubation and post-intubation conditions. Both dexmedetomidine and remifentanil were effective as sedatives in patients undergoing awake fiberoptic nasotracheal intubation. Compared with remifentanil, dexmedetomidine offered better endoscopy scores, lower recall of intubation, and greater patient satisfaction, with minor hemodynamic side effects.

Efficacy of T-joint endoscopy mask for fiberoptic bronchoscopy-guided awake nasotracheal intubation in patients with cervical spinal cord injury

Objective To evaluate the efficacy of T-joint endoscopy mask for fiberoptic bronchoscopy （FOB）-guided awake nasotraeheal intubation in patients with cervical spinal cord injury. Methods Forty patients of both sexes aged 21-64 yr with fracture of cervical spine complicated by spinal cord injury scheduled for anterior decompression and interbody fusion under general anesthesia were randomly divided into 2 groups according to the technique for awake nasotracheal intubation （ n = 20 each） ： group nasal catheter and group T-joint endoscopy mask. Topical anesthesia of nasal cavity, pharynx, larynx and trachea with 2 % lidocaine was conducted and then remifentanil was continuously infused at 0.05-0.15 ~g＂ kg-1 ~ min-1 in both groups. The incidence of hypoxemia and intubation time were recorded. Arterial blood samples were obtained for determination of PaO2 and PaCO2 be- fore topical anesthesia （baseline）, immediately before and 1 min after placement of FOB and immediately after na- sotracheal intubation was accomplished. Results The incidence of hypoxemia was significantly lower in group T- joint endoscopy mask （0） than in group nasal catheter （25 % ）（ P 〈 0.05 ）. The PaO2 during nasotracheal intuba- tion was significantly higher in group T-joint endoscopy mask than in group nasal catheter （P 〈 0.05）. There was no significant difference in PaCO2 and intubation time between the 2 groups （ P 〉 0.05）. Conclusion T-joint en- doscopy mask facilitates awake nasotracheal intubation without affecting oxygen inhalation in patients with cervical spinal cord injuries. Key words: Laryngeal masks; Brenchoscopy; Intubation, intratracheal; Spinal cord injuries

Direct laryngoscopy should be procedure of choice in the airway management of patients with dental cellulitis

Airway management of patients with dental cellulitis can be difficult due to laryngeal deviation and oedema. Awake fibre-optic intubation has been recommended. The aim of this study was to assess our routine procedure which is based mainly on direct laryngoscopy. This was a prospective observational study. In a single centre between February 2008 and February 2009. All patients suffering from dental cellulitis and requiring emergency surgery were included except pregnant women and patients under 18 years. Nasotracheal intubation by direct laryngoscopy under general anaesthesia was performed unless the supine position was not tolerated, or difficult mask ventilation or intubation was anticipated, when awake nasotracheal fibre-optic intubation was indicated. In the case of failure at the first attempt, orotracheal intubation by direct laryngoscopy was attempted. If failure persisted, tracheotomy was then performed. The principal endpoint was the incidence of difficult mask ventilation which was expected to be less than 5%. Secondary endpoints were the incidence of difficult tracheal intubation and tracheotomy. We included 127 consecutive patients (mouth opening 20±10 mm). One did not tolerate the supine position and was successfully intubated using the fiberscope. Among the 126 remaining, difficult mask ventilation did not occur [0%, 95% confidence interval (CI) 0-3%], 124 (98%) patients were intubated by direct laryngoscopy and two (2%) required tracheotomy. Retrognathia (odds ratio 8.2, 95% CI 1.3-50.1) and extension to oral floor (odds ratio 15.1, 95% CI 1.8-129.5) were significantly associated with the prediction of intubation failure at the first attempt. Most patients with dental cellulitis can be safely intubated through direct laryngoscopy even if mouth opening is limited.

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

A comparison of efficacy of dexmedetomidine and sufentanil used to supplement topical anesthesia for fiberoptic bronchoscopy-assisted naso-tracheal intubation in patients with obstructive sleep apnea syndrome

目的 比较阻塞性睡眠呼吸暂停综合征(OSAS)患者右美托咪啶和舒芬太尼辅助表面麻醉用于纤维支气管镜(纤支镜)引导经鼻气管插管的效果.方法 全麻下行择期手术的OSAS患者30例,性别不限,ASA分级Ⅱ或Ⅲ级,年龄32 ～ 58岁,体重75 ～ 105 kg.采用随机数字表法,将患者随机分为2组(n=20):舒芬太尼组(S组)和右美托咪啶组(D组).2组均应用2％利多卡因咽喉喷雾表面麻醉,环甲膜穿刺注射1％丁卡因3 ml.S组经60 s静脉注射舒芬太尼0.1μg/kg,给药后3 min开始实施纤支镜引导经鼻气管插管,D组静脉输注右美托咪啶0.1μg·kg-1·min-1 10 min时开始实施纤支镜引导经鼻气管插管,记录气道阻塞评分.记录麻醉诱导开始至气管插管后3 min内MAP和HR的最大值,计算MAP和HR的变化率、RPP＞ 22 000以及呼吸抑制等的发生情况.分别于麻醉前、纤支镜通过鼻后孔、窥视会厌、气管插管成功时、气管插管后1 min、气管插管后3 min时记录灌注指数(PI)和Ramsay镇静评分.术后24h随访患者,记录声音嘶哑和咽喉疼痛的发生情况.结果 与S组比较,D组气道阻塞评分、呼吸抑制的发生率降低,PI、Ramsay镇静评分、MAP变化率＞30％、HR变化率＞30％、RPP＞ 22 000、咽喉疼痛和声音嘶哑的发生率差异无统计学意义(P＞0.05).结论 与舒芬太尼比较,右美托咪啶辅助表面麻醉用于OSAS患者纤支镜引导经鼻气管插管不抑制呼吸,可提供良好的气管插管条件。

Obstruction iatrogène sévère de la voie aérienne par un lymphangiome lingual

Lymphangioma of the tongue is a rare and benign tumour involving congenital and cystic abnormalities derived from lymphatic vessels. Treatment modalities include surgery and a large number of different intralesional injections of sclerosing agents. Presently, OK-432 (Picibanil(®)) is the preferred sclerosant and when administered intralesionally will result in inflammation, sclerosis, and cicatricial contraction of the lesion. We report a case of microcystic lymphangioma of the tongue in a 5-year-old boy treated with an intralesional injection of OK-432. In the immediate postoperative period, the patient suffered severe diffuse swelling, progressive upper airway obstruction with inspiratory stridor, and respiratory distress requiring emergency fiberoptic nasotracheal intubation. Although OK-432 injections are found to be safe and effective as a first line of treatment for lymphangiomas, local swelling with potentially life-threatening airway compromise should be anticipated, especially when treating lesions near the upper airway.

Awake nasotracheal fiber-optic intubation in a patient with severe gunshot injury to the face: Case Report

Facial trauma significantly increases the difficulty in airway management in the emergency department or during the provision of anesthesia for surgery. We present airway management in a patient with severe facial trauma that necessitated awake nasotracheal fiber-optic intubation for safe induction of anesthesia.

The Effect site concentration of remifentanil for suppressing severe cough and defensive movement during awake fibreoptic nasotracheal intubation in patients undergoing cervical spine surgery

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Local and Regional Anaesthesia

Topical anaesthesia of the vocal cords by nebulized lignocaine inhalation to facilitate fi breoptic nasotracheal intubation in a head-size parotid tumour patient

This case report describes a successful fibreoptic naso-tracheal intubation in a patient with difficult airway due to a nearly head-size right parotid swelling. Nasal fibreoptic intubation was performed by maintaining spontaneous breathing under propofol infusion at a dose of 25 mcg/kg/hour and topical anaesthesia of vocal cords by using oxygen (6 l/min) flow to nebulize 4% lignocaine from the side port of the fibreoptic bronchoscope. The topical anaesthesia was achieved by keeping the scope in close proximity of the vocal cords and in the centre of view of the scope. This case emphasizes the possibility of fibreoptic intubation in a sedated yet spontaneously breathing patient by allowing inhalation of nebulized lignocaine during fibreoptic intubation.

Topical vasoconstrictor use for nasal intubation during pregnancy complicated by cardiomyopathy and preeclampsia

Ankylosing spondylitis presents challenges for the obstetric anesthesiologist in administering neuraxial anesthesia or managing the airway. A pregnant patient with ankylosing spondylitis, cardiomyopathy and preeclampsia requiring cesarean delivery was managed with an awake nasotracheal fiberoptic intubation. The use of topical cocaine, epinephrine, phenylephrine, and oxymetazoline to produce nasal vasoconstriction is discussed. Selective alpha-2 agonists that can potentially provide nasal mucosa vasoconstriction and placental vasculature vasodilation are also discussed.

Nasotracheal fibreoptic intubation: a randomised controlled trial comparing the GlideRite® (Parker‐Flex® Tip) nasal tracheal tube with a standard pre‐rotated nasal RAETM tracheal tube

In a randomised controlled study, we compared the ease of railroading a GlideRite® nasal tracheal tube over a fibrescope with that of a pre-rotated RAE™ nasal tracheal tube. We studied 110 anaesthetised patients with no known airway difficulties undergoing elective dental or maxillofacial surgery. Impingement was more common with the GlideRite tubes (11/55 (20%)) compared with the pre-rotated RAE tubes (3/55 (5%); p=0.02). The median (IQR [range]) time to intubation (GlideRite 7.6 (4.7-10.8 [3.0-46.2]) s; RAE 8.0 (6.2-10.7 [2.4-30.0]) s) and postoperative sore throat numerical ratings (GlideRite 2 (0-3 [0-10]); RAE 2 (0-5 [0-8])) were similar. A 90° anticlockwise pre-rotation of a standard nasal RAE tube has a higher initial rate of successful railroading at first attempt and is therefore superior to a GlideRite nasotracheal tube during nasal fibreoptic intubation.

Perioperative management of patients for osteo-odonto-kreatoprosthesis under general anaesthesia: A retrospective study

An osteo-odonto-keratoprosthesis (OOKP) procedure is indicated in patients with failed corneal transplant but having intact retina for visual improvement. We studied perioperative concerns of patients who underwent the staged OOKP procedure. This was a retrospective analysis of patients who underwent OOKP. The information regarding symptoms, associated comorbidities, perioperative events including anaesthetic management were collected. Eight patients (five females and three males) underwent the staged OOKP procedure. The median age was 18 years. The median weight was 45 kg. The median duration of loss of vision was 4 years. The aetiology of blindness included Stevens-Johnson's syndrome (SJS) (7) and chemical burn (1). Four patients had generalized skin problem due to SJS. All cases were managed under general anaesthesia, and airway management included nasotracheal intubation for stage I and orotracheal intubation for stage II. The median mallampati classification was I prior to OOKP stage I procedure while it changed to II at stage II procedure. Two patients required fibreoptic nasotracheal intubation. One patient had excessive oozing from the mucosal harvest site and was managed conservatively. In one patient, tooth harvesting was done twice as the first tooth was damaged during creating a hole in it. We conclude that OOKP requires multidisciplinary care. Anaesthesiologist should evaluate the airway carefully and disease-associated systemic involvements. The use of various drugs requires caution and steroid supplementation should be done. Airway difficulty should be anticipated, mandating thorough evaluation. Re-evaluation of airway is prudent as it may become difficult during the staged OOKP procedure.

Is the intubating laryngeal mask tube really superior to the flexometallic tracheal tube for fibreoptic nasotracheal intubation?

We read with interest the recent article of Rai et al. [1], that concluded that the incidence of tracheal tube impingement during fibreoptic nasotracheal intubation is significantly lower with the intubating laryngeal mask (ILMA) tube than with the flexometallic tracheal tube. We believe it would be more appropriate to conclude that the ILMA tube is better only when the flexometallic tracheal tube is improperly orientated during passage. In this study, once the flexometallic tracheal tube was rotated anticlockwise by 90°, its success rate improved to 29 out of 30 patients, essentially the same as the success rate (30 out of 30) of the ILMA tube. It may be more appropriate always to start with the flexometallic tracheal tube orientated in a 90° anticlockwise direction. This technique has been used previously during awake fibreoptic orotracheal intubation, resulting in a higher success rate of intubation at the first attempt (100%) compared to the conventional approach (60%) [2]. Rotation of the bevelled tracheal tube randomly may reduce the difficulty in advancing a tracheal tube over a fibrescope, but 90° anticlockwise rotation should be effective in reducing impingement of the tracheal tube [3]. This manoeuvre was first suggested by Schwartz et al. [4]. Maktabi et al. [5] recommend 90° anticlockwise rotation as the first step to overcome difficulty in advancing the tracheal tube. Ho et al. [6] and Wheeler et al. [7] also suggested that the first attempt at railroading the tracheal tube should be done with the tracheal tube already turned in a 90° anticlockwise direction. In our practice, simple rotation of bevelled tracheal tubes anticlockwise by 90° during the first attempt has become a routine part of fibreoptic intubation [8]. This study by Rai et al. [1] should help popularise this. In the abstract, the authors conclude that compared to the ILMA tube, the incidence of laryngeal trauma from fibreoptic nasotracheal intubation may be significantly greater with the flexometallic tracheal tube, due to the higher incidence of glottic impingement. However, we find no evidence to support this in their results. This is concerning as in our experience, many readers do not read beyond the abstract of an article, and may then be misled by this statement. It may have been preferable to compare the two tubes for the severity of epistaxis, nasal pain, sore throat and dysphonia observed on the first post operative day. Both the flexometallic tracheal tube and ILMA tube lack a Ring-Adair-Elwin contour. For this reason, we feel that these tubes are not suitable choices for nasotracheal intubation for oral cavity and jaw surgery, as surgical access may be limited due to vertical protrusion of the tracheal tube from the nostrils. The absence of the distal curve of these tubes does not allow the breathing system to be positioned away from the surgical field without the use of an additional connector. The ILMA tube also requires a higher cuff pressure, which makes it less desirable, particularly in patients requiring nasotracheal intubation for a prolonged period.

A comparison of the effectiveness of dexmedetomidine versus propofol target‐controlled infusion for sedation during fibreoptic nasotracheal intubation

Fibreoptic intubation is a valuable modality for airway management. This study aimed to compare the effectiveness of dexmedetomidine vs target controlled propofol infusion in providing sedation during fibreoptic intubation. Forty patients with anticipated difficult airways and due to undergo tracheal intubation for elective surgery were enrolled and randomly allocated into the dexmedetomidine group (1.0 microg.kg(-1) over 10 min) (n = 20) or the propofol target controlled infusion group (n = 20). Intubating conditions and patient tolerance as graded by a scoring system were evaluated as primary outcomes. Intubation was successful in all patients. Satisfactory intubating conditions were found in both groups (19/20 in each group). The median (IOR [range]) comfort score was 2 (1-2 [1-4]) in the dexmedetomidine group and 3 (2-4 [2-5]) in the propofol group (p = 0.027), favouring the former. The dexmedetomidine group experienced fewer airway events and less heart rate response to intubation than the propofol group (p < 0.003 and p = 0.007, respectively). Both dexmedetomidine and propofol target-controlled infusion are effective for fibreoptic intubation. Dexmedetomidine allows better tolerance, more stable haemodynamic status and preserves a patent airway.

Jaw Thrust Improves the Fiberoptic Laryngeal View during Fiberoptic Nasotracheal Intubation

Jaw Thrust Improves the Fiberoptic Laryngeal View during Fiberoptic Nasotracheal Intubation

A comparison of a flexometallic tracheal tube with the intubating laryngeal mask tracheal tube for nasotracheal fibreoptic intubation using the two‐scope technique*

We compared the incidence and site of impingement of a flexometallic tracheal tube with those of the re-usable intubating laryngeal mask (ILMA) tube in 60 anaesthetised patients undergoing nasotracheal fibreoptic intubation for oral surgery. A two-scope technique was used, observing the site of impingement with one scope whilst intubating with the other. The tubes were 6.0-mm in females and 6.5-mm in males. Impingement occurred with 10 (33%) flexometallic and 2 (7%) ILMA tubes (p < 0.032). In all but one case, the impingement was posterior to the right arytenoid cartilage. When impingement was observed, a single disempaction with a 90 degrees anticlockwise rotational manoeuvre overcame impingement in every case except one, allowing successful intubation. We conclude that the incidence of impingement of the tracheal tube, and therefore of potential laryngeal trauma from nasotracheal fibreoptic intubation, is significantly greater with the flexometallic tube than with the ILMA tube.

Iatrogenic Foreign Body (Cotton Swab) in the Trachea after Nasotracheal Intubation

We describe our experience about a 3-inch cotton swab being misplaced in the trachea following nasotracheal intubation. A 67-year-old male patient was scheduled for oral cancer surgery. Before nasotracheal intubation, an oxymetazoline hydrochloride-soaked 3-inch cotton swab was inserted into right nostril for nasal mucosal vasoconstriction. Unpredictable difficult ventilation and intubation occurred during anesthesia induction and then fiberoptic bronchoscope-aided nasotracheal intubation was performed. The cotton swab was inconceivably found in the trachea by fiberoptic bronchoscope, and it was removed immediately by thoracic surgeon. This case demonstrates a near-miss complication during anesthesia induction. We discuss the factors which may contribute to this complication.

A Comparison of Propofol and Remifentanil Target-Controlled Infusions to Facilitate Fiberoptic Nasotracheal Intubation

Successful fiberoptic intubation requires both patient comfort and good intubating conditions. In this study we compared the efficacy and ease of titration of propofol (P) and remifentanil (R) target-controlled infusions (TCI) during fiberoptic intubation. Sixty patients requiring fiberoptic nasotracheal intubation were randomized to receive (P) or (R) effect-site TCI. After topical anesthesia, TCI was set to 2.5 microg/mL (P) or 1.5 ng/mL (R) then titrated by 1 microg/mL (P) or 0.5 ng/mL (R) increments according to patient reactions. Targets and level of sedation were recorded at each step as well as total dose, number of adjustments, intubating conditions, discomfort, and recall assessed after surgery. Intubation duration, success rate, and number of increments did not differ between groups. Intubating conditions were good in both groups, with a final target of 3.9 +/- 1.4 microg/mL (P) or 2.4 +/- 0.8 ng/mL (R) (total dose 142 +/- 55 mg and 77 +/- 27 microg, respectively). There was no difference in minimal SpO(2) and maximal end-tidal CO(2) after intubation. No laryngospasm or significant hemodynamic instability was observed. There was one major hypoxemia due to obstructive apnea in group P. Patients in group P were significantly more sedated and less cooperative. Recall was more frequent in group R, whereas pain scores were equally low in both groups. Both R and P TCI can be rapidly titrated to achieve good intubating conditions and patient comfort. R allows for more patient cooperation, making it safer when spontaneous ventilation is paramount.

The Effect of Laryngeal View Grade and Intraoral Bleeding on Intubation Difficulty during Fiberoptic Nasotracheal Intubation

The Effect of Laryngeal View Grade and Intraoral Bleeding on Intubation Difficulty during Fiberoptic Nasotracheal Intubation