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Merola R, Vargas M, Marra A, Buonanno P, Coviello A, Servillo G, Iacovazzo C. Videolaryngoscopy versus Fiberoptic Bronchoscopy for Awake Tracheal Intubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2024; 13:3186. [PMID: 38892899 PMCID: PMC11173084 DOI: 10.3390/jcm13113186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Background: In recent years, videolaryngoscopy has increasingly been utilized as an alternative to fiberoptic bronchoscopy in awake intubation. Nonetheless, it remains uncertain whether videolaryngoscopy represents a viable substitute for fiberoptic bronchoscopy. We conducted this systematic review with a meta-analysis to compare videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. Methods: We systematically searched for all randomized controlled trials (RCTs) comparing videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. The Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE were systematically queried through August 2023. Our primary outcome measure was the duration of intubation. Secondary outcomes encompassed the rate of successful intubation on the initial attempt, failed intubation, patient-reported satisfaction, and any complications or adverse events potentially stemming from the intubation procedure. The Cochrane Risk of Bias Tool for RCTs was employed to evaluate all studies for evidence of bias. The GRADE approach was utilized to gauge the certainty of the evidence. Results: Eleven trials involving 873 patients were ultimately included in our review for data extraction. Meta-analysis demonstrated that videolaryngoscopy decreased the duration of intubation compared to fiberoptic bronchoscopy (SMD -1.9671 [95% CI: -2.7794 to -1.1548] p < 0.0001), a finding corroborated in subgroup analysis by the type of videolaryngoscope (SMD -2.5027 [95% CI: -4.8733 to -0.1322] p = 0.0385). Additionally, videolaryngoscopy marginally lowered the risk of experiencing a saturation below 90% during the procedure (RR -0.7040 [95% CI: -1.4038 to -0.0043] p = 0.0486). No statistically significant disparities were observed between the two techniques in terms of failed intubation, initial successful intubation attempt, or sore throat/hoarseness. With regard to patient-reported satisfaction, a pooled analysis was precluded due to the variability in evaluation methods employed across the trials to assess this outcome. Lastly, trial sequential analysis (TSA) conducted for intubation time (primary outcome) affirmed the conclusiveness of this evidence; TSA performed for secondary outcomes failed to yield conclusive evidence, indicating the necessity for further trials. Conclusions: Videolaryngoscopy for awake tracheal intubation diminishes intubation time and the risk of experiencing a saturation below 90% compared to fiberoptic bronchoscopy.
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Affiliation(s)
- Raffaele Merola
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, Via Pansini 5, 80100 Naples, Italy; (M.V.); (A.M.); (P.B.); (A.C.); (G.S.); (C.I.)
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Pirlich N, Berk A, Hummel R, Schmidtmann I, Epp K, Kriege M, Wittenmeier E. Awake tracheal intubation in routine airway management: A retrospective analysis in a tertiary centre. PLoS One 2024; 19:e0299071. [PMID: 38427680 PMCID: PMC10906896 DOI: 10.1371/journal.pone.0299071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 02/03/2024] [Indexed: 03/03/2024] Open
Abstract
INTRODUCTION While awake tracheal intubation (ATI) is regarded as the gold standard for difficult airway management according to current guidelines, there seems to be a reluctance in its application. This retrospective cohort study, conducted at a German tertiary hospital over a 2-year period, aimed to demonstrate that integrating awake tracheal intubation using flexible bronchoscopy (ATI:FB) into routine airway management makes it a successful and safe approach. MATERIALS AND METHODS In 2019 and 2020, records from the data acquisition system (DAQ) and archived anesthesia records were screened to evaluate the specifics of ATI:FB procedures, focusing on overall success and safety. Analysis included complications, time required for ATI:FB, and potential influencing factors such as patient characteristics, indication, medical/operative specialty, sedation technique, route and experience of anesthesiologist. Logistic regression assessed the impact of various variables on occurrence of complications and linear regression, with log(time) as the dependent variable, evaluated median time required to perform ATI:FB. RESULTS ATI:FB constituted 4.3 % (n = 1,911) of all airway management procedures, predominantly observed in dental, oral, and maxillofacial surgery (46.5 %) and otorhinolaryngology (38.4 %). The success rate for ATI:FB was notably high at 99.6 %, with only 5.4 % of cases experiencing complications, including technical issues, agitation, and visibility obstruction due to mucous secretion. Complication risk was influenced by the medical specialty and the experience of the anesthesiologist. A strong effect was observed in otorhinolaryngology (OR = 4.54, 95 % CI [1.64; 14.06]). The median time required for ATI:FB was 16 minutes (IQR: 11 to 23), with factors such as indication (p < 0.0001), experience of anesthesiologist (p < 0.0001), sedation technique (p = 0.0408), priority of the procedure (p = 0.0134), and medical/operative specialty (p < 0.0001) affecting the duration. The median time required for ATI:FB differed significantly based on the experience of the anesthesiologist (p < 0.0001). CONCLUSION ATI:FB proves successful and safe, with low complications and manageable procedural time. Experience of the anesthesiologist is a modifiable factor enhancing safety, emphasizing the need for ATI:FB integration into routine airway management.
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Affiliation(s)
- Nina Pirlich
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Alexander Berk
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Regina Hummel
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Katharina Epp
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Marc Kriege
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva Wittenmeier
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:207-247. [PMID: 38340790 DOI: 10.1016/j.redare.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitary Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology. Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Emergency Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Heidegger T, Asai T. Fibreoptic intubation: a commitment to an indispensable technique. Br J Anaesth 2023; 131:793-796. [PMID: 37479592 DOI: 10.1016/j.bja.2023.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 07/23/2023] Open
Abstract
Recent evidence has shown that fibreoptic intubation is still an indispensable technique for safe management of predicted difficult airways, despite the implementation of new technologies such as videolaryngoscopy. It is therefore our obligation as anaesthesia societies and as practicing anaesthetists to offer this technique to our patients in clearly designated situations.
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Affiliation(s)
- Thomas Heidegger
- Department of Anaesthesia, Spital Grabs, Grabs, Switzerland; Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Centre, Koshigaya, Saitama, Japan
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Karlsen KAH, Gisvold SE, Nordseth T, Fasting S. Incidence, causes, and management of failed awake fibreoptic intubation-A retrospective study of 833 procedures. Acta Anaesthesiol Scand 2023; 67:1341-1347. [PMID: 37587618 DOI: 10.1111/aas.14313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/18/2023]
Abstract
Awake fibreoptic intubation has been considered a gold standard in the management of the difficult airway. However, failure may cause critical situations. The aim of this study was to investigate the incidence and causes of failed awake fibreoptic intubation at a tertiary care hospital. The study was conducted at St. Olav University Hospital in Trondheim, Norway. Problems occurring during anaesthesia are routinely recorded in the electronic anaesthesia information system (Picis Clinical Solutions Inc.), including difficult intubations. We applied text search on all anaesthesia records between 2011 and 2021 and identified 833 awake fibreoptic intubations. The anaesthesia records were examined to identify failed awake fibreoptic intubations, the cause of failure and how the airway ultimately was secured. Among 233,938 patients who received anaesthesia, 90,397 received tracheal intubation and 833 received awake fibreoptic intubation. Twenty-nine of the procedures failed. In nine patients the failure caused loss of airway control with desaturation and hypoventilation. The major causes of failure were dislodged tube after induction of general anaesthesia (n = 8), patient distress (n = 5), tube not able to pass (n = 5), and airway bleeding (n = 3). The situations were primarily solved using direct laryngoscopy, with or without bougie, or with video laryngoscopy. Tracheostomy was performed in four patients. Awake fibreoptic intubation failed in 3.5% of patients, most often due to dislocation, problems passing the tracheal tube, or patient discomfort. The failure rate was higher than in previous studies.
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Affiliation(s)
| | - Sven Erik Gisvold
- Department of Anaesthesia and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging. Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Trond Nordseth
- Department of Anaesthesia and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging. Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Sigurd Fasting
- Department of Anaesthesia and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging. Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Zhang T, Zhao KY, Zhang P, Li RH. Comparison of video laryngoscope, video stylet, and flexible videoscope for transoral endotracheal intubation in patients with difficult airways: a randomized, parallel-group study. Trials 2023; 24:599. [PMID: 37735666 PMCID: PMC10512610 DOI: 10.1186/s13063-023-07641-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND The 2022 ASA guidelines recommend the video laryngoscope, video stylet, and flexible videoscope as airway management tools. This study aims to compare the efficacy of three airway devices in intubating patients with difficult airways. METHODS A total of 177 patients were selected and randomized into the following three groups: the video laryngoscope group (Group VL, n = 59), video stylet group (Group VS, n = 59), and flexible videoscope group (Group FV, n = 59). The success rate of the first-pass intubation, time of tracheal intubation, level of glottic exposure, and occurrence of intubation-related adverse events were recorded and analyzed. RESULTS All patients were successfully intubated with three devices. The first-pass intubation success rate was significantly higher in Groups VS and FV than in Group VL (96.61% vs. 93.22% vs. 83.05%, P < 0.01), but it was similar in the first-pass intubation success rate between Groups VS and FV(P > 0.05). The number of patients categorized as Wilson-Cormack-Lehane grade I-II was fewer in Group VL than in Groups VS and FV (77.97% vs. 98.30% vs. 100%, P = 0.0281). The time to tracheal intubation was significantly longer in Group FV(95.20 ± 4.01) than in Groups VL(44.56 ± 4.42) and VS(26.88 ± 4.51) (P < 0.01). No significant differences were found among the three groups in terms of adverse intubation reactions (P > 0.05). CONCLUSIONS In patients with difficult airways requiring intubation, use of the video stylet has the advantage of a relatively shorter intubation time, and the flexible videoscope and video stylet yield a higher first-pass intubation success rate and clearer glottic exposure than the use of the video laryngoscope. TRIAL REGISTRATION Chinese Clinical Trial Registry. No: ChiCTR2200061560, June 29, 2022.
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Affiliation(s)
- Tao Zhang
- Department of Anesthesiology, Lu'an Hospital of Anhui Medical University, Lu'an, Anhui, China
| | - Kai-Yuan Zhao
- Department of Anesthesiology, Lu'an Hospital of Anhui Medical University, Lu'an, Anhui, China
| | - Ping Zhang
- Department of Anesthesiology, Lu'an Hospital of Anhui Medical University, Lu'an, Anhui, China
| | - Ren-Hu Li
- Department of Anesthesiology, Lu'an Hospital of Anhui Medical University, Lu'an, Anhui, China.
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Marchis IF, Zdrehus C, Pop S, Radeanu D, Cosgarea M, Mitre CI. Awake nasotracheal intubation with a 300-mm working length fiberscope: a prospective observational feasibility trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:556-562. [PMID: 34843803 PMCID: PMC10533966 DOI: 10.1016/j.bjane.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 10/11/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Awake fiberoptic tracheal intubation is an established method of securing difficult airways, but there are some reservations about its use because many practitioners find it technically complicated, time-consuming, and unpleasant for patients. Our main goal was to test the safety and efficacy of a 300-mm working length fiberscope (video rhino-laryngoscope) when used for awake nasotracheal intubation in difficult airway cases. METHODS This was a prospective, single-center study involving adult patients, having an ASA physical status between I and IV, with laryngopharyngeal pathology causing distorted airway anatomy. Awake nasotracheal intubation, using topical anesthesia and light sedation, was performed using a 300 mm long and 2.9 mm diameter fiberscope equipped with a lubricated reinforced endotracheal tube. The primary outcomes were the success and duration of the procedure. Patients' periprocedural satisfaction and other incidents were recorded. RESULTS We successfully intubated all 25 patients included in this study. The mean ±SD duration of the procedure, starting from the passage of the intubating tube through one of the nostrils until the endotracheal intubation, was 76 ± 36 seconds. Most of the patients showed no discomfort during the procedure with statistical significance between the No reaction Group with the Slight grimacing Group (95%CI 0.13, 0.53, p = 0.047) and the Heavy grimacing Group (95%CI 0.05, 0.83, p = 0.003). The mean ±SD satisfaction score 24 hours post-intervention was 1.8 ± 0.86 - mild discomfort. No significant incidents occurred. CONCLUSIONS Our study showed that a 300-mm working length flexible endoscope is fast, safe, and well-tolerated for nasotracheal awake intubation under challenging airways.
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Affiliation(s)
- Ioan Florin Marchis
- University of Medicine and Pharmacy "Iuliu Hatieganu", Anaesthesia and Intensive Care Department, Cluj- Napoca, Romania.
| | - Claudiu Zdrehus
- University of Medicine and Pharmacy "Iuliu Hatieganu", Anaesthesia and Intensive Care Department, Cluj- Napoca, Romania
| | - Sever Pop
- University of Medicine and Pharmacy "Iuliu Hatieganu", Otorhinolaryngology Department, Cluj- Napoca, Romania
| | - Doinel Radeanu
- University of Medicine and Pharmacy "Iuliu Hatieganu", Otorhinolaryngology Department, Cluj- Napoca, Romania
| | - Marcel Cosgarea
- University of Medicine and Pharmacy "Iuliu Hatieganu", Otorhinolaryngology Department, Cluj- Napoca, Romania
| | - Calin Iosif Mitre
- University of Medicine and Pharmacy "Iuliu Hatieganu", Anaesthesia and Intensive Care Department, Cluj- Napoca, Romania
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Tsukamoto M, Goto M, Hitosugi T, Yokoyama T. The difference in rotation angle of the distal endotracheal tube through nasal approach. BMC Anesthesiol 2023; 23:272. [PMID: 37568085 PMCID: PMC10416368 DOI: 10.1186/s12871-023-02225-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Nasal intubation using a fiberoptic scope is a useful technique. In clinical practice, we have experienced difficulty in advancing the endotracheal tube (ETT) over the fiberoptic scope because of resistance to the passage of the ETT against rotation in the nasal cavity, when it gets hung up on structures of the laryngeal inlet. Several maneuvers have been proposed to overcome this difficulty. The gap between the tip of the ETT and the fiberoptic scope can be reduced using a thicker fiberoptic scope and a thinner ETT. Moreover, simultaneous rotation of the fiberoptic scope and ETT could lead to successful intubation by reducing impingement on the ETT. However, the discrepancy between these rotation angles is unclear. This observational prospective study aimed to investigate the discrepancy in the rotation angle between the ETT and fiberoptic scope during nasal intubation. METHODS The patients (aged 20-80 years) who underwent nasal intubation for oral and maxillofacial surgery participated in three sizes of preformed nasal ETT and were intubated using a fiberoptic scope. They were divided into three groups; the ETT internal diameter (ID) 6.5 mm (6.5 group), ID 7.0 mm (7.0 group), and ID 7.5 mm (7.5 group). The ETT was then inserted through the nasal cavity into the pharynx. After the fiberoptic scope was advanced through the ETT above the glottis, simultaneous rotation by both the proximal end of the fiberoptic scope and ETT was performed in 90° and 180° in both right (clockwise) and left (counterclockwise) directions, and the rotation angle at the distal end of the ETT was monitored using a video laryngoscope (Pentax-AWS). RESULTS A total of 39 patients were included in the study. When both the proximal end of the fiberscope and ETT were simultaneously rotated by 90°, in the 6.5 group (n = 13), the distal end of the ETT rotated by 47.8 ± 1.5°. In the 7.0 °group (n = 13), the distal end of the ETT rotated by 45.5 ± 1.0°. In the 7.5 group (n = 13), the distal end of the ETT rotated by 39.9 ± 1.0°. When the proximal end of the fiberscope and ETT were rotated by 180°, in the 6.5 group, the distal end of the ETT rotated by 166.2 ± 2.5°. In the 7.0 group, the distal end of the ETT rotated by 145.7 ± 2.2°. In the 7.5 group, the distal end of the ETT rotated by 115.1 ± 2.0°. All rotation angles in the distal end of the ETT were significantly lower than those in both the proximal end of the fiberscope and ETT (p < 0.05). Rotating right by 180° was significantly different among the three groups (p < 0.05), although rotating right by 90° was not significantly different. Similar results were obtained for the left rotation. CONCLUSION Simultaneous rotation by the proximal end of the ETT and fiberscope above the glottis for the nasal approach induced significant differences in the distal end of the ETT. The larger tube lagged by the resistance of the nasal passages during rotation. Therefore, the ETT does not rotate as much as the rotation angle. TRIAL REGISTRATION This prospective observational study was conducted after receiving approval from the Ethics Review Board of Kyushu University Hospital (Approval No. 30-447).
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Affiliation(s)
- Masanori Tsukamoto
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
| | - Maho Goto
- Department of Dental Anesthesiology, Graduate School of Dental Science, Kyushu University, Fukuoka, Japan
| | - Takashi Hitosugi
- Department of Dental Anesthesiology, Graduate School of Dental Science, Kyushu University, Fukuoka, Japan
| | - Takeshi Yokoyama
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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Law JA, Thana A, Milne AD. In reply: Awake tracheal intubation: what can be done to maintain the skill? Can J Anaesth 2023; 70:1270-1271. [PMID: 37138152 DOI: 10.1007/s12630-023-02477-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 05/05/2023] Open
Affiliation(s)
- J Adam Law
- Department of Anesthesia, Pain Management & Perioperative Medicine, QEII Health Sciences Centre, Halifax Infirmary Site, Dalhousie University, Halifax, NS, Canada.
| | - Apiraami Thana
- Department of Anesthesia, Pain Management & Perioperative Medicine, QEII Health Sciences Centre, Halifax Infirmary Site, Dalhousie University, Halifax, NS, Canada
| | - Andrew D Milne
- Department of Anesthesia, Pain Management & Perioperative Medicine, QEII Health Sciences Centre, Halifax Infirmary Site, Dalhousie University, Halifax, NS, Canada
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Kamga H, Frugier A, Boutros M, Bourges J, Doublet T, Parienti JJ. Flexible nasal bronchoscopy vs. Airtraq ® videolaryngoscopy for awake tracheal intubation: a randomised controlled non-inferiority study. Anaesthesia 2023. [PMID: 37188387 DOI: 10.1111/anae.16042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/17/2023]
Abstract
Videolaryngoscopy is a suitable alternative to flexible bronchoscopy to facilitate awake tracheal intubation. The relative effectiveness of these techniques in clinical practice is unknown. We compared flexible nasal bronchoscopy with Airtraq® videolaryngoscopy in patients with an anticipated difficult airway scheduled for awake tracheal intubation. Patients were allocated randomly to flexible nasal bronchoscopy or videolaryngoscopy. All procedures were performed with upper airway regional anaesthesia blockade and a target-controlled intravenous infusion of remifentanil. The success rate with the allocated technique was the primary outcome. A non-inferiority analysis with a predefined limit of 8% was planned. Seventy-eight patients were recruited, allocated randomly and analysed. The rate of successful intubation was 97% and 82% in the flexible bronchoscopy and videolaryngoscopy groups, respectively, p = 0.032. The median (IQR [range]) time to tracheal intubation was shorter with the Airtraq, 163 (105-332 [40-1004]) vs. 217 (180-364 [120-780]) s, p = 0.030. There were no significant differences for complications found between the groups. The median visual analogue scale for ease of intubation was 8 (7-9 [0-10]) for Airtraq vs. 8 (7-9 [0-10]) for flexible bronchoscopy, p = 0.710. The median visual analogue scale for patient comfort for Airtraq was 8 (6-9 [2-10]) vs. 8 (7-9 [3-10]) for flexible bronchoscopy, p = 0.370. The Airtraq videolaryngoscope is not non-inferior to flexible bronchoscopy for awake tracheal intubation in a clinical setting when awake tracheal intubation is indicted. It may be a suitable alternative when judged on a case-by-case basis.
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Affiliation(s)
- H Kamga
- Centre Hospitalier Universitaire de Caen, Caen, France
| | - A Frugier
- Centre Hospitalier Universitaire de Caen, Caen, France
| | - M Boutros
- Centre Hospitalier Universitaire de Caen, Caen, France
| | - J Bourges
- Centre Hospitalier Universitaire de Caen, Caen, France
| | - T Doublet
- Centre Hospitalier Universitaire de Caen, Caen, France
| | - J J Parienti
- Centre Hospitalier Universitaire de Caen, Caen, France
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11
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Zheng J, Du L, Du B, Zhang W, Zhang L, Chen G. Airway nerve blocks for awake tracheal intubation: A meta-analysis of randomized control trials and trial sequential analysis. J Clin Anesth 2023; 88:111122. [PMID: 37054484 DOI: 10.1016/j.jclinane.2023.111122] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/30/2023] [Accepted: 04/05/2023] [Indexed: 04/15/2023]
Abstract
STUDY OBJECTIVE This systematic review and meta-analysis aimed to assess the superiority of airway nerve blocks versus airway anesthesia without nerve blocks for awake tracheal intubation (ATI). DESIGN Systematic review and meta-analysis of randomized controlled trials (RCTs). SETTING All studies that assessed the superiority of airway anesthesia technique for awake tracheal intubation were searched in PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase and Chinese databases (including China National Knowledge Infrastructure, Wanfang database, and VIP databases) and trial registry databases from their inception to December 2022. PATIENTS Adult patients included in randomized controlled trials comparing airway anesthesia with or without airway nerve blocks for ATI. INTERVENTIONS Airway nerve (including superior laryngeal nerve, glossopharyngeal nerve, or recurrent laryngeal nerve) blocks for ATI. MEASUREMENTS The primary outcome was the intubation time. Secondary outcomes were quality of intubating conditions (including patient reaction to placement of the flexible scope and tracheal tube, coughing and gagging, and patient satisfaction) and overall complications during ATI. MAIN RESULTS Fourteen articles with 658 patients were identified for analysis. When compared with airway anesthesia without nerve blocks, airway nerve blocks significantly reduced intubation time (standardized mean difference [SMD] -2.57, 95% CI -3.59- -1.56, p < 0.00001), improved anesthesia quality of ATI with higher no reaction to placement of the flexible scope and tracheal tube (relative risk [RR] 9.87; 95% CI 4.10-23.75, p < 0.00001), lower cough or gag reflex during intubation (RR 0.35, 95% CI 0.27-0.46, p < 0.00001), higher excellent patient satisfaction rate (RR 1.88, 95% CI 1.05-3.34, p = 0.03), and lower overall complications (RR 0.29, 95% CI 0.19-0.45, p < 0.00001). The overall quality of evidence was moderate. CONCLUSIONS Based on current published evidence, airway nerve blocks provide better airway anesthesia quality for ATI with a shorter intubation time, better intubation conditions including higher no reaction to placement of the flexible scope and tracheal tube, lower cough or gag reflex during intubation, higher excellent patient satisfaction, and lower overall complications.
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Affiliation(s)
- Jianqiao Zheng
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37th, Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan, China
| | - Li Du
- Department of Anesthesiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, No.55th, People's South Road, Chengdu 610041, Sichuan, China
| | - Bin Du
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37th, Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan, China
| | - Weiyi Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37th, Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan, China.
| | - Lu Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37th, Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan, China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37th, Guoxue Alley, Wuhou District, Chengdu 610041, Sichuan, China.
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12
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Lundstrøm LH, Nørskov AK, Kjeldgaard LD, Wetterslev J, Rosenstock CV. Implementation of video laryngoscopes and the development in airway management strategy and prevalence of difficult tracheal intubation: A national cohort study. Acta Anaesthesiol Scand 2023; 67:159-168. [PMID: 36307961 DOI: 10.1111/aas.14165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND We aimed to determine the development in the use of video laryngoscopy over a 9-year period, and its possible impact on airway planning and management. METHODS We retrieved 822,259 records of tracheal intubations recorded from 2008 to 2016 in the Danish Anaesthesia Database. The circumstances regarding pre-operative airway assessment, the scheduled airway management plan and the actual airway management concerning video laryngoscopy were reported for each year of observation. Further, the association between year of observation and various airway management related outcomes was evaluated by multivariate logistic regression. RESULTS There was a significant increase in airway management with 'advanced technique successfully used within two attempts' from 2.7% in 2008 to 15.5% in 2016 (p < .0001). This predominantly reflects use of video laryngoscopy. The prevalence of tracheal intubations 'scheduled for video laryngoscopy' increased from 3.5% in 2008 to 10.6% in 2016 (p < .0001). We found a significant increase in the prevalence of anticipated difficulties with intubations by direct laryngoscopy from 1.8% in 2008 to 5.2% in 2016 (p < .0001). The prevalence of failed tracheal intubations decreased from 0.14% in 2008 to 0.05% in 2016 (p < .0001). CONCLUSION From 2008 to 2016, a period of massive implementation of video laryngoscopes, a significant change in airway management behaviour was recorded. Increasingly, video laryngoscopy is becoming a first-choice device for both acute and routine airway management. Most importantly, the data showed a noticeable reduction in failed intubation over the time of observation.
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Affiliation(s)
- Lars Hyldborg Lundstrøm
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders K Nørskov
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Line D Kjeldgaard
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jørn Wetterslev
- Private Office, Tuborg Sundpark 3, Hellerup, Copenhagen, Denmark
| | - Charlotte V Rosenstock
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark
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13
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Meena K, Meena RK, Palanisamy D, Deepesh, Nayak AP. An innovative technique for nasotracheal fiberoptic intubation using SNPA and its comparison with conventional technique: RCT. Natl J Maxillofac Surg 2023; 14:41-46. [PMID: 37273437 PMCID: PMC10235747 DOI: 10.4103/njms.njms_120_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/08/2022] [Accepted: 09/19/2022] [Indexed: 11/02/2023] Open
Abstract
Background Awake nasotracheal fiberoptic intubation by conventional technique is time consuming and requires expertise. Complications encountered in the conventional technique sometime leads to procedure failure. Objective The primary aim of this study was to compare the innovative technique using split nasopharyngeal airway (SNPA) with the conventional technique for nasotracheal fiberoptic intubation in terms of time taken for intubation. Method This was a prospective, randomized, and single blind study conducted with 80 patients who were scheduled for maxillofacial surgery. Patients were randomized into two groups, group CFBI (conventional fiberoptic intubation) and group SNPA (split nasopharyngeal airway). In both the groups patients were prepared for awake fiberoptic naso-tracheal intubation. In Group CFBI (N = 41) awake naso-tracheal intubation was achieved by conventional technique of bronchoscope first approach. In Group SNPA (N = 39) spirally split nasopharyngeal airway was used first as a conduit for the passage of fiberoptic bronchoscope. The primary objective was to assess the time taken for intubation. The secondary objectives were to assess the rate of complications in the form of bleeding, cough, desaturation during the procedure, laryngospasm, and nasal bleeding. Result The time taken for intubation was 6.15 ± 3.0 minutes in CFBI group and 3.10 ± 1.35 minutes in SNPA group and this this difference was statically significant with P value <0.001. Desaturation during the procedure was more in CFBI (99.46 ± 0.75) compared to SNPA (99 ± 0) group with significant difference P value <0.001. Conclusion Split nasopharyngeal airway was used as conduit for the passage for the flexible fibreoptic bronchoscope and it considerably reduced the time required for fiberoptic nasotracheal intubation compared to the conventional technique of endotracheal tube first approach. Split nasopharyngeal airway provided better intubating conditions with lesser complications and superior patient comfort.
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Affiliation(s)
- Kavita Meena
- Department of Anaesthesiology, IMS, BHU, Varanasi, Uttar Pradesh, India
| | | | - Deepak Palanisamy
- Department of Anaesthesiology, G Kuppusamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Deepesh
- Department of Anaesthesiology, IMS, BHU, Varanasi, Uttar Pradesh, India
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14
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Law JA, Thana A, Milne AD. The incidence of awake tracheal intubation in anesthetic practice is decreasing: a historical cohort study of the years 2014-2020 at a single tertiary care institution. Can J Anaesth 2023; 70:69-78. [PMID: 36289151 PMCID: PMC9607858 DOI: 10.1007/s12630-022-02344-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 06/09/2022] [Accepted: 07/07/2022] [Indexed: 11/05/2022] Open
Abstract
PURPOSE Awake tracheal intubation (ATI) is recommended in airway management guidelines when significant difficulty is predicted with airway management. Use of the technique may be declining, which may have implications for patient safety or for skills acquisition and maintenance. This historical cohort database study sought to determine if the use of ATI was decreasing in our adult tertiary care center. METHODS With institutional research ethics board approval, we queried our anesthesia information management system for cases with ATI descriptors for each year from 2014 to 2020. Records of the retrieved cases were independently reviewed by all three authors to verify they met inclusion criteria for the ATI cohort prior to analysis for the primary outcome. Secondary outcome measures included airway device and route used for ATI, first attempt and ultimate success rates, and reported adverse issues recorded in cases of failed ATI or those requiring more than one attempt. RESULTS A total of 692 cases of ATI were identified between 2014 and 2020. There was a statistically significant decrease in yearly ATIs over the seven-year study period (Chi square goodness of fit, P < 0.001), with ATI use decreasing by about 50%. First attempt success was significantly greater with use of flexible bronchoscopy vs video laryngoscopy to facilitate ATI (84% vs 60%; P < 0.001), while there was no difference in first attempt success with the oral vs nasal route (82% vs 82%; P = 1.0). CONCLUSION In this single-center historical cohort study, the use of ATI decreased significantly from 2014 to 2020. Whether this decrease will result in morbidity or mortality related to airway management is currently unclear. Regardless, it has implications for training opportunities and maintenance of competence in performing the procedure.
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Affiliation(s)
- J Adam Law
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, QEII Health Sciences Centre, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS, B3H 3A7, Canada.
| | - Apiraami Thana
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, QEII Health Sciences Centre, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS, B3H 3A7, Canada
| | - Andrew D Milne
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, QEII Health Sciences Centre, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS, B3H 3A7, Canada
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15
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Kim HJ, Kim MS, Kim SY, Min IK, Park WK, Song SH, Shin D, Kim HJ. A propensity score-adjusted analysis of efficacy of high-flow nasal oxygen during awake tracheal intubation. Sci Rep 2022; 12:11306. [PMID: 35788661 PMCID: PMC9253013 DOI: 10.1038/s41598-022-15608-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/27/2022] [Indexed: 11/09/2022] Open
Abstract
Oxygen supplementation is crucial for awake tracheal intubation (ATI) using a flexible bronchoscope in patients with an anticipated difficult airway. However, the modality of optimal oxygen delivery remains unclear. This retrospective study compared high-flow nasal oxygen (HFNO) and conventional low-flow oxygen supply during ATI. We applied inverse probability of treatment weighting (IPTW) to account for biases due to clinical characteristic differences between the groups. The primary endpoint was the lowest oxygen saturation during ATI. The secondary endpoints were incidence of desaturation, multiple attempts, failure rate, and procedural duration. After IPTW adjustment, the lowest oxygen saturation in the HFNO group during ATI was significantly higher than that in the conventional oxygenation group (99.3 ± 0.2 vs. 97.5 ± 0.5, P < 0.001). Moreover, the HFNO group had fewer cases with multiple attempts than the conventional oxygenation group (3% vs. 16%, P = 0.007). There were no significant differences between the two groups in the incidence of desaturation, failure and procedural duration. Our findings suggest that HFNO was associated with improved lowest oxygen saturation and a lower rate of multiple attempts during ATI. Therefore, we recommend using HFNO for safer oxygen delivery and improved quality of procedure during ATI.
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Affiliation(s)
- Hye Jin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Min-Soo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - In Kyung Min
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Wyun Kon Park
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sei Han Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Dongkwan Shin
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyun Joo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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16
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Butler K, Winters M. The Physiologically Difficult Intubation. Emerg Med Clin North Am 2022; 40:615-627. [DOI: 10.1016/j.emc.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Awake Intubation Techniques, and Why It Is Still an Important Skill to Master. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00529-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Rosenblatt WH, Yanez ND. A Decision Tree Approach to Airway Management Pathways in the 2022 Difficult Airway Algorithm of the American Society of Anesthesiologists. Anesth Analg 2022; 134:910-915. [PMID: 35171880 PMCID: PMC8986631 DOI: 10.1213/ane.0000000000005930] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The American Society of Anesthesiologists’ (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to guide the anesthesiologist’s choice of pathway in the ASA’s Difficult Airway Algorithm. The tool prompts the anesthesiologist to consider the risk of difficulty with laryngoscopy (direct or indirect) and tracheal intubation, facemask or supraglottic ventilation, gastric contents aspiration, and rapid oxyhemoglobin desaturation. For every airway management event, the approach integrates the anesthesiologist’s unique combination of experience, expertise, patient anatomy and disease, equipment availability, and other contextual conditions into the decision process. Entry into the awake intubation pathway is encouraged when the patient is judged at risk of difficult tracheal intubation and one or more of the following: difficult ventilation, significant aspiration risk, and/or rapid oxyhemoglobin desaturation. The decision tree tool is anticipated to improve communication between anesthesiologists and others by clearly identifying those factors of concern and how decision-making is affected by those concerns.
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Affiliation(s)
- William H Rosenblatt
- From the Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
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19
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Dean P, Kerrey B. Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review. J Am Coll Emerg Physicians Open 2022; 3:e12630. [PMID: 35028640 PMCID: PMC8738719 DOI: 10.1002/emp2.12630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization. METHODS We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization. RESULTS We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies. CONCLUSIONS Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.
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Affiliation(s)
- Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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20
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Tube tip in pharynx-a conduit for awake oral intubation in patients with extremely restricted mouth opening. Can J Anaesth 2021; 69:504-508. [PMID: 34907504 DOI: 10.1007/s12630-021-02174-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Awake flexible bronchoscope-guided intubation is challenging in patients with extremely limited mouth opening (when there is inadequate space for an oropharyngeal airway), especially when nasal access is unavailable. Alternatives include awake front of neck access, which is an invasive procedure and not suitable for elective surgery. We present a novel technique to facilitate flexible bronchoscope-guided oral intubation in these patients. CLINICAL FEATURES Tube tip in pharynx (TTIP) is a technique for establishing a patent airway if ventilation is difficult or has failed using a face mask, supraglottic airway, or endotracheal tube. The technique involves placing the tip of the endotracheal tube in the pharynx, 10-14 cm past the teeth, filling the cuff with air, closing the mouth and nose of the patient, and then initiating ventilation. The TTIP method thus combines the function of an oropharyngeal airway and a face mask akin to a supraglottic airway device, but is more flexible with regard to insertion depth and cuff inflation and demands only minimal mouth opening. We have adapted the TTIP technique for awake flexible bronchoscope-guided oral intubation and report the technique illustrated with three cases where mouth opening was so restricted that it precluded insertion of an oropharyngeal airway. CONCLUSION By placing an endotracheal tube with the tip in the pharynx, TTIP can establish a conduit for awake oral flexible bronchoscope-guided intubation in patients with extremely limited mouth opening and unavailable nasal access. This technique requires equipment that is readily available and may help avoid unnecessary awake tracheostomy.
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21
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Awake fiberoptic intubation: A narrative clinical review based on the Cleveland Clinic experience. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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22
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Wang Z, Yang Y, Chen Y, Yi B, Lu K, Chen B. Fiberoptic-guided tracheal intubation under precise anesthesia and topicalization with spontaneous respiration preservation for an uncooperative patient with severe postburn mentosternal contracture. Clin Case Rep 2021; 9:e05208. [PMID: 34934504 PMCID: PMC8650747 DOI: 10.1002/ccr3.5208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/04/2021] [Accepted: 09/08/2021] [Indexed: 11/16/2022] Open
Abstract
Airway management of patients with difficult airways is a challenge to the anesthesiologists and awake tracheal intubation is the recommended strategy. Successful fiberoptic-guided tracheal intubation under precise anesthesia and topicalization with spontaneous respiration preservation was achieved in an uncooperative patient with severe postburn mentosternal contracture scheduled for release of contracture.
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Affiliation(s)
- Zhi Wang
- Department of AnesthesiaSouthwest HospitalArmy Military Medical UniversityChongqingChina
| | - Yong Yang
- Department of AnesthesiaSouthwest HospitalArmy Military Medical UniversityChongqingChina
| | - Yang Chen
- Department of AnesthesiaSouthwest HospitalArmy Military Medical UniversityChongqingChina
| | - Bin Yi
- Department of AnesthesiaSouthwest HospitalArmy Military Medical UniversityChongqingChina
| | - Kaizhi Lu
- Department of AnesthesiaSouthwest HospitalArmy Military Medical UniversityChongqingChina
| | - Bing Chen
- Department of AnesthesiaThe Second Affiliated Hospital of Chongqing Medical UniversityChongqingChina
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23
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Desai N, Ratnayake G, Onwochei DN, El-Boghdadly K, Ahmad I. Airway devices for awake tracheal intubation in adults: a systematic review and network meta-analysis. Br J Anaesth 2021; 127:636-647. [PMID: 34303493 DOI: 10.1016/j.bja.2021.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Awake tracheal intubation is commonly performed with flexible bronchoscopes, but the emerging role of alternative airway devices, such as videolaryngoscopes, direct laryngoscopes, and optical stylets, has been recognised. METHODS CENTRAL, CINAHL, EMBASE, MEDLINE, and Web of Science were searched for RCTs that compared flexible bronchoscopes, direct laryngoscopes, optical stylets and channelled or unchannelled videolaryngoscopes in adult patients having awake tracheal intubation were included. The co-primary outcomes were first-pass success rate and time to tracheal intubation. Continuous outcomes were extracted as mean and standard deviation, and dichotomous outcomes were converted to overall numbers of incidence. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced. RESULTS Twelve RCTs were included, none of which evaluated direct laryngoscopes. The first-pass success rate was not different between flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes, with the quality of evidence rated as moderate in view of imprecision. Optical stylets, followed by unchannelled videolaryngoscopes and then felxible bronchoscopes resulted in the shortest time to tracheal intubation, with the quality of evidence rated as high. No differences were shown between the airway devices with respect to the incidence of oesophageal intubation, change of airway technique, oxygen desaturation, airway bleeding, or the rate of hoarseness and sore throat. CONCLUSIONS Flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes were clinically comparable airway devices in the setting of awake trachela intubation and the time to tracheal intubation was shortest with optical stylets and longest with flexible bronchoscopes.
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Affiliation(s)
- Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK.
| | - Gamunu Ratnayake
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Desire N Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK
| | - Kariem El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK
| | - Imran Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK
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Van Zundert AA, Endlich Y, Beckmann LA, Bradley WP, Chapman GA, Heard AM, Heffernan D, Jephcott CG, Khong GL, Rehak A, Semenov RA, Stefanutto TB, O'Sullivan E. 2021 Update on airway management from the Anaesthesia Continuing Education Airway Management Special Interest Group. Anaesth Intensive Care 2021; 49:257-267. [PMID: 34154374 DOI: 10.1177/0310057x20984784] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Airway Management is the key for anaesthetists dealing with patients undergoing diagnostic procedures and surgical interventions. The present coronavirus pandemic underpins even more how important safe airway management is. It also highlights the need to apply stringent precautions to avoid infection and ongoing transmission to patients, anaesthetists and other healthcare workers (HCWs). In light of this extraordinary global situation the aim of this article is to update the reader on the varied aspects of the ever-changing tasks anaesthetists are involved in and highlight the equipment, devices and techniques that have evolved in response to changing technology and unique patient and surgical requirements.
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Affiliation(s)
- André Aj Van Zundert
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Yasmin Endlich
- Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, Australia
| | - Linda A Beckmann
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | - Gordon A Chapman
- Department of Anaesthesia, Royal Perth Hospital, Perth, Australia
| | - Andrew Mb Heard
- Department of Anaesthesia, Royal Perth Hospital, Perth, Australia
| | - Drew Heffernan
- Department of Anaesthesia, St Vincent's Hospital, Darlinghurst, Australia
| | | | - Geraldine Ls Khong
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Adam Rehak
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Richard A Semenov
- Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, Australia
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Jauho KR, Johannsen ML, Hesselfeldt RT, Kristensen MS. Infrared flashing light through the cricothyroid membrane to guide flexible bronchoscopic tracheal intubation. Anaesth Rep 2021; 9:114-117. [PMID: 34099999 DOI: 10.1002/anr3.12119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 12/18/2022] Open
Abstract
Flexible bronchoscopic tracheal intubation is a fundamental technique in the management of the difficult airway but requires specific skills which may be both difficult to achieve and maintain. Therefore, techniques to improve its success should be developed. We present two cases, one where the ear, nose and throat surgeon could not view the glottis due to laryngeal pathology, and one where pathology in the oropharynx obscured access to the trachea during attempts at flexible bronchoscopic and videolaryngoscopic tracheal intubation. In both cases, tracheal intubation was subsequently successful due to the use of the Infrared Red Intubation System. This is an infrared light source that is secured to the anterior neck. It emits a flashing infrared light that is captured by the flexible bronchoscope, thus guiding the way to the trachea. These are the first reports of this technology being used for flexible bronchoscopic tracheal intubation in patients with severe airway pathology where conventional approaches had failed. Both cases emphasise that this technique can be of benefit in avoiding a surgical airway.
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Affiliation(s)
- K R Jauho
- Department of Anaesthesiology Centre of Head and Orthopaedics, Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - M L Johannsen
- Department of Anaesthesiology Centre of Head and Orthopaedics, Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - R T Hesselfeldt
- Department of Anaesthesiology Centre of Head and Orthopaedics, Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - M S Kristensen
- Department of Anaesthesiology Centre of Head and Orthopaedics, Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
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Xu Q, Zhou Z, Ai L, Liu J, Tian X. Sufentanil EC50 for endotracheal intubation with aerosol inhalation of carbonated lidocaine by ultrasonic atomizer. BMC Anesthesiol 2021; 21:144. [PMID: 33980156 PMCID: PMC8114505 DOI: 10.1186/s12871-021-01367-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nebulized lidocaine reduced stress response for endotracheal intubation. However, the impact of novel lidocaine aerosol inhalation for intubation by ultrasonic atomizer was unclear. Hence, we designed aerosol inhalation of lidocaine by ultrasonic atomizer, to seek whether the dosage of sufentanil for intubation could be less or not. METHODS Intravenous injection of sufentanil started at 0.5 μg/kg, and sufentanil dosage was increased/decreased (step-size 0.05 μg/kg for sufentanil) using Dixon's up and down method. The observation was terminated after 8 reflexes. RESULTS The EC50 and EC95 of sufentanil with lidocaine by ultrasonic atomizer for intubation were found to be 0.232 μg/kg (95% CI: 0.187-0.270 μg/kg) and 0.447 μg/kg (95% CI: 0.364-0.703 μg/kg). 55.88% out of 34 patients showed hemodynamic index change < 20% of baseline during intubation. CONCLUSION Aerosol inhalation of lidocaine by ultrasonic atomizer reduced the dosage of sufentanil for endotracheal intubation. Lidocaine inhalation by ultrasonic atomizer for airway anesthesia with minimal dosage of sufentanil could be recommended, particularly in patients who need more stable hemodynamic changes or spontaneous respiration. TRIAL REGISTRATION Chinese Registry of Central Trial, ChiCTR-IOR-17014198 . Registered 28 December 2017.
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Affiliation(s)
- Qiaoqiao Xu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, Hubei, China
| | - Zhiqiang Zhou
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, Hubei, China
| | - Ling Ai
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, Hubei, China
| | - Jieqiong Liu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, Hubei, China
| | - Xuebi Tian
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, Hubei, China.
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Difficult airway management practice changes after introduction of the GlideScope videolaryngoscope: A retrospective cohort study. Eur J Anaesthesiol 2021; 37:443-450. [PMID: 32205576 DOI: 10.1097/eja.0000000000001199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Introduction of the GlideScope videolaryngoscope caused a change in use of other devices for difficult airway management. OBJECTIVE The influence of the GlideScope videolaryngoscope on changes in the indications for and the frequency of use of flexible fibreoptic-assisted intubation and other difficult airway management techniques. DESIGN Retrospective cohort study. SETTING Tertiary care referral centre. METHODS Two periods of equal length (647 days each) before and after introducing the GlideScope were compared. Information about patients who were intubated using nondirect laryngoscopic techniques were analysed. Data were retrieved from the anaesthesia and hospital information management systems. RESULTS Difficult airway management techniques were used in 235/8306 (2.8%) patients before and in 480/8517 (5.6%) (P < 0.0001) patients after the introduction of the GlideScope. There was an overall 44.4% reduction in use of flexible fibreoptic bronchoscopy after GlideScope introduction [before 149/8306 (1.8%); after 85/8517 (1.0%), P < 0.0001]. The GlideScope replaced flexible fibreoptic bronchoscopy in most cases with expected and unexpected difficult intubation. In patients with limited mouth opening, flexible fibreoptic bronchoscopy was still mostly the first choice after the introduction of the GlideScope. There was a 70% reduction in the use of other difficult intubation techniques after the introduction of the GlideScope [before 84/8306 (1.0%); after 22/8517 (0.3%), P < 0.0001)]. CONCLUSION The GlideScope videolaryngoscope replaced flexible fibreoptic bronchoscopy for most patients with expected and unexpected difficult intubation. In the case of limited mouth opening, flexible fibreoptic bronchoscopy was still the first choice after the introduction of the GlideScope. The reduced use of flexible fibreoptic bronchoscopy raises concerns that residents may not be adequately trained in this essential airway management technique. GlideScope use was disproportionately greater than the reduction in the use of flexible fibreoptic bronchoscopy and other difficult intubation techniques. This may be attributed to resident teaching and use in patients with low-to-moderate suspicion of difficult intubation.
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Syal R, Parvez M, Kothari N, Abbas H, Kumar R, Singh S, Choudhary G. Comparison of Conventional Technique versus Modified Tube First Technique of Awake Nasotracheal Fiber-optic Intubation: A Randomized Control Open-Label Trial. Anesth Essays Res 2021; 14:395-400. [PMID: 34092848 PMCID: PMC8159060 DOI: 10.4103/aer.aer_104_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/08/2020] [Accepted: 01/08/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Although the conventional awake fiber-optic nasal intubation is most commonly used in anticipated difficult tracheal intubation, it has several potential difficulties. Aims: The aim of this study is to compare another technique modified tube first (MTF) technique with the conventional one in terms of time taken, ease of glottis visualization, number of attempts needed, and complications. Settings and Design: This was a prospective, randomized, open-label trial conducted on 60 patients with an anticipated difficult airway undergoing oromaxillofacial surgery at a tertiary care center. Materials and Methods: The patients were randomized into the MTF and conventional technique groups. Times from insertion of the fiber-optic scope into nares till vocal cord visualization (T1) and from T1 to complete intubation (T2) were measured and compared. Statistical Analysis Used: Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 21. Results: Time taken to visualize glottis was significantly less in the MTF technique as compared to the conventional method (mean ± standard deviation = 108.6 ± 43.1 vs. 142 ± 49.2 s, respectively, P = 0.007). Similarly, the total time taken for nasotracheal intubation with modified technique is significantly less as compared to the conventional technique (P = 0.004). Furthermore, there is significantly better ease of glottis visualization (P = 0.001), higher success in minimal attempts (P = 0.02) with significantly lesser incidence of desaturation in MTF technique (P = 0.026). Conclusion: The alternative technique (MTF) is a quicker, easier approach with higher success rate and lesser complications for the placement of an endotracheal tube in a difficult airway scenario.
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Affiliation(s)
- Rashmi Syal
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mohammed Parvez
- Department of Anesthesiology and Critical Care, King George's University of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nikhil Kothari
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Haider Abbas
- Department of Emergency Medicine, King George's University of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rakesh Kumar
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Garima Choudhary
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth 2021; 68:1405-1436. [PMID: 34105065 PMCID: PMC8186352 DOI: 10.1007/s12630-021-02008-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient's tolerance for withdrawal of airway support and whether re-intubation might be difficult.
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30
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Wang H, Ford RZ, Milne AD. Differences in aerosol flow rates between disposable and reusable atomizers used for airway topicalization: implications for local anesthetic toxicity. Can J Anaesth 2020; 68:270-271. [PMID: 33210219 DOI: 10.1007/s12630-020-01856-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/24/2020] [Accepted: 10/28/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Haotian Wang
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
| | - R Zachary Ford
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Andrew D Milne
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.,School of Biomedical Engineering, Dalhousie University, Halifax, NS, Canada
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Roh GU, Kang JG, Han JY, Chang CH. Utility of oxygen insufflation through working channel during fiberoptic intubation in apneic patients: a prospective randomized controlled study. BMC Anesthesiol 2020; 20:282. [PMID: 33167909 PMCID: PMC7654027 DOI: 10.1186/s12871-020-01201-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Airway management is a part of routine anesthetic procedures; however, serious complications, including hypoxia and death, are known to occur in cases of difficult airways. Therefore, alternative techniques such as fiberoptic bronchoscope-assisted intubation (FOB intubation) should be considered, although this method requires more time and offers a limited visual field than does intubation with a direct laryngoscope. Oxygen insufflation through the working channel during FOB intubation could minimize the risk of desaturation and improve the visual field. Therefore, the aim of this prospective randomized controlled study was to evaluate the utility and safety of oxygen insufflation through the working channel during FOB intubation in apneic patients. METHODS Thirty-six patients were randomly allocated to an N group (no oxygen insufflation) or an O group (oxygen insufflation). After preoxygenation, FOB intubation was performed with (O group) or without (N group) oxygen insufflation in apneic patients. The primary outcome was the velocity of decrease in the partial pressure of oxygen (PaO2) during FOB intubation (VPaO2, mmHg/sec) defined as the difference of PaO2 before and after intubation divided by the time to intubation. The secondary outcomes included the success rate for FOB intubation, time to intubation, visual field during FOB intubation, findings of arterial blood gas analysis, and occurrence of FOB intubation-related complications. RESULTS We found that VPaO2 was significantly greater in the N group than in the O group (1.0 ± 0.4 vs. 0.4 ± 0.4; p < 0.001), while the visual field was similar between groups. There were no significant intergroup differences in the secondary outcomes. CONCLUSIONS These findings suggest that oxygen insufflation through the working channel during FOB intubation aids in extending the apneic window during the procedure. TRIAL REGISTRATION ClinicalTrials.gov , NCT02625194 , registered at December 9, 2015.
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Affiliation(s)
- Go Un Roh
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnami-si, Gyeonggi-do, 13496, Korea
| | - Joon Gwon Kang
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnami-si, Gyeonggi-do, 13496, Korea
| | - Jung Youn Han
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnami-si, Gyeonggi-do, 13496, Korea
| | - Chul Ho Chang
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Korea.
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El-Boghdadly K, Ahmad I. The safety of topical lidocaine for awake tracheal intubation: a reply. Anaesthesia 2020; 75:1260-1261. [PMID: 32583895 DOI: 10.1111/anae.15101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - I Ahmad
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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33
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El-Boghdadly K, Ahmad I. Sedation strategies in awake tracheal intubation: a reply. Anaesthesia 2020; 75:689-690. [PMID: 32557559 DOI: 10.1111/anae.14970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - I Ahmad
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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34
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Sakles JC, Pacheco GS, Kovacs G, Mosier JM. The difficult airway refocused. Br J Anaesth 2020; 125:e18-e21. [PMID: 32402374 DOI: 10.1016/j.bja.2020.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- John C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.
| | - Garrett S Pacheco
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - George Kovacs
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA; Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, University of Arizona College of Medicine, Tucson, AZ, USA
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Hyman JB, Apatov D, Katz D, Levine AI, DeMaria S. A Prospective Observational Study of Video Laryngoscopy Use in Difficult Airway Management. Laryngoscope 2020; 131:82-86. [PMID: 32212339 DOI: 10.1002/lary.28637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/25/2020] [Accepted: 03/03/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Video laryngoscopy has grown tremendously in popularity over the last decade for management of the anticipated difficult airway. The use of video laryngoscopy has not been adequately studied in the head and neck pathology patient population, including those with masses, previous head and neck surgery, or radiation. STUDY DESIGN Prospective observational study. METHODS This study included 100 patients with head and neck pathology undergoing awake flexible bronchoscopic intubation for nonemergency surgery requiring general anesthesia. After the performance of awake flexible bronchoscopic intubation and induction of anesthesia, video laryngoscopy was performed with the CMAC D blade and Glidescope AVL. The primary outcome was the modified Cormack-Lehane view obtained on video laryngoscopy. RESULTS One hundred patients were enrolled in the study. After exclusions, 92 patients underwent video laryngoscopy with both the CMAC D blade and the Glidescope AVL. Thirty-seven patients (40.2%) had a Cormack-Lehane view ≥3 with the CMAC D blade, and 28 patients (30.4%) had a Cormack-Lehane view ≥3 with the Glidescope AVL. There were no complications from awake flexible bronchoscopic intubation or video laryngoscopy. CONCLUSIONS There is a high incidence of inability to obtain a view of the glottis with video laryngoscopy in patients with head and neck pathology, particularly airway masses. LEVEL OF EVIDENCE 3 Laryngoscope, 131:82-86, 2021.
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Affiliation(s)
- Jaime B Hyman
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - David Apatov
- Department of Anesthesiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York, U.S.A
| | - Daniel Katz
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Adam I Levine
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
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Touré T, Williams SR, Kerouch M, Ruel M. Patient factors associated with difficult flexible bronchoscopic intubation under general anesthesia: a prospective observational study. Can J Anaesth 2020; 67:706-714. [PMID: 31953669 DOI: 10.1007/s12630-020-01568-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Patient characteristics associated with difficult tracheal intubation using a flexible bronchoscope (FB) under general anesthesia have not been prospectively evaluated. This observational study aimed to identify demographic and morphologic factors associated with difficult FB intubation. METHODS We recruited 420 adult elective surgery patients undergoing tracheal intubation during general anesthesia. Patients characteristics were recorded including age, sex, weight, height, body mass index, American Society of Anesthesiologists physical status, history of snoring, obstructive sleep apnea, Mallampati score, upper lip bite test score, neck circumference and skinfold thickness, maximal neck flexion and extension angles, absence of teeth, Cormack and Lehane grade, presence of blood or secretions during intubation, as well as the inter-incisor, thyromental, sternothyroid, and manubriomental distances. The time (duration) needed to complete intubation (primary endpoint) and the number of attempts needed were correlated with these patient characteristics in a multivariable analysis. RESULTS Intubation was successful on the first attempt in 409/420 patients (97%). Seven patients (1.7%) needed more than one attempt. Failure to intubate with the FB occurred in four patients (1%). A correlation was found between intubation duration and visibility impaired by secretions or blood (P < 0.001), higher neck skinfold thickness (P < 0.001), and larger endotracheal tube diameter (relative to a constant 5.5 mm FB; P < 0.001). CONCLUSIONS The presence of secretions or blood that impair FB glottic visualization, a larger diameter endotracheal tube on the same size FB, as well as higher neck skinfold thickness may prolong the duration of FB intubation under general anesthesia. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02769819); registered 5 May, 2016.
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Affiliation(s)
- Taher Touré
- Département d'anesthésiologie, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Stephan R Williams
- Département d'anesthésiologie, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada.
| | - Mahmoud Kerouch
- Département d'anesthésiologie, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Monique Ruel
- Département d'anesthésiologie, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
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37
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Aziz MF, Kristensen MS. From variance to guidance for awake tracheal intubation. Anaesthesia 2019; 75:442-446. [PMID: 31828761 DOI: 10.1111/anae.14947] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 12/18/2022]
Affiliation(s)
- M F Aziz
- Department of Anesthesiology and Peri-operative Medicine, Oregon Health and Science University, Portland, OR, USA
| | - M S Kristensen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University Hospital of Copenhagen, Denmark
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39
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Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2019; 75:509-528. [PMID: 31729018 PMCID: PMC7078877 DOI: 10.1111/anae.14904] [Citation(s) in RCA: 189] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2019] [Indexed: 12/13/2022]
Abstract
Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.
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Affiliation(s)
- I Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - R Bhagrath
- Department of Anaesthesia, Barts Health NHS Trust, London, UK
| | - I Hodzovic
- Department of Anaesthesia, Cardiff University School of Medicine, Cardiff, UK.,Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, UK
| | - A F McNarry
- Department of Anaesthesia, NHS Lothian, Edinburgh, UK
| | - F Mir
- Department of Anaesthesia, St. George's University Hospital NHS Foundation Trust, London, UK
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, Dublin, Ireland
| | - A Patel
- Department of Anaesthesia, Royal National Throat Nose and Ear Hospital and University College London Hospitals NHS Foundation Trust, London, UK
| | - M Stacey
- Department of Anaesthesia, Cardiff and Vale NHS Trust (HEIW), Cardiff, UK
| | - D Vaughan
- Department of Anaesthesia, Northwick Park Hospital, London, UK
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Grange K, Mushambi M, Jaladi S, Athanassoglou V. Techniques and complications of awake fibre-optic intubation – A Survey of Difficult Airway Society members. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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41
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Lim WY, Wong P. Awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review. Korean J Anesthesiol 2019; 72:548-557. [PMID: 31475506 PMCID: PMC6900415 DOI: 10.4097/kja.19318] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/27/2019] [Indexed: 12/26/2022] Open
Abstract
Awake intubation is indicated in difficult airways if attempts at securing the airway after induction of general anesthesia may lead to harm due to potential difficulties or failure in those attempts. Conventional awake flexible bronchoscopic intubation is performed via the nasal, or less commonly, oral route. Awake oral flexible bronchoscopic intubation (FBI) via a supraglottic airway device (SAD) is a less common technique; we refer to this as ‘supraglottic airway guided’ FBI (SAGFBI). We describe ten cases with anticipated difficult airways in which awake SAGFBI was performed. After sedation and adequate airway topicalization, an Ambu AuragainTM SAD was inserted. A flexible bronchoscope, preloaded with a tracheal tube, was then inserted through the SAD. Finally, the tracheal tube was railroaded over the bronchoscope, through the SAD and into the trachea. The bronchoscope and the SAD were carefully removed, whilst keeping the tracheal tube in-situ. The technique was successful and well tolerated by all patients, and associated complications were rare. It also offered the advantages of performing an ‘awake test insertion’ of the SAD, an ‘awake look’ at the periglottic region, and an ‘awake test ventilation.’ In certain patients, awake SAGFBI offers advantages over conventional awake FBI or awake videolaryngoscopy. More research is required to evaluate its success and failure rates, and identify associated complications. Its place in difficult airway algorithms may then be further established.
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Affiliation(s)
- Wan Yen Lim
- Department of Anesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Patrick Wong
- Department of Anesthesiology, Singapore General Hospital, Singapore, Singapore
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Morrison S, Aerts S, Van Rompaey D, Vanderveken O. Failed Awake Intubation for Critical Airway Obstruction Rescued With the Ventrain Device and an Arndt Exchange Catheter: A Case Report. A A Pract 2019; 13:23-26. [DOI: 10.1213/xaa.0000000000000975] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Godoroja D, Sorbello M, Margarson M. Airway management in obese patients: The need for lean strategies. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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El-Boghdadly K, Onwochei DN, Cuddihy J, Ahmad I. Current practice for awake fibreoptic intubation - asking the right questions. Anaesthesia 2019; 72:1149-1150. [PMID: 28804883 DOI: 10.1111/anae.14014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - D N Onwochei
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J Cuddihy
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - I Ahmad
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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El-Boghdadly K, Onwochei DN, Cuddihy J, Ahmad I. A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre. Anaesthesia 2018; 72:694-703. [PMID: 28654138 DOI: 10.1111/anae.13844] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2017] [Indexed: 12/22/2022]
Abstract
Contemporary data are lacking for procedural practice, training provision and outcomes for awake fibreoptic intubation in the UK. We performed a prospective cohort study of awake fibreoptic intubations at a tertiary centre to assess current practice. Data from 600 elective or emergency awake fibreoptic intubations were collected to include information on patient and operator demographics, technical performance and complications. This comprised 1.71% of patients presenting for surgery requiring a general anaesthetic, with the majority occurring in patients presenting for head and neck surgery. The most common indication was reduced mouth opening (26.8%), followed by previous airway surgery or head and neck radiotherapy (22.5% each). Only five awake fibreoptic intubations were performed with no sedation, but the most common sedative technique was combined target-controlled infusions of remifentanil and propofol. Oxygenation was achieved with high-flow, heated and humidified oxygen via nasal cannula in 49.0% of patients. Most operators had performed awake fibreoptic intubation more than 20 times previously, but trainees were the primary operator in 78.6% of awake fibreoptic intubations, of which 86.8% were directly supervised by a consultant. The failure rate was 1.0%, and 11.0% of awake fibreoptic intubations were complicated, most commonly by multiple attempts (4.2%), over-sedation (2.2%) or desaturation (1.5%). The only significant association with complications was the number of previous awake fibreoptic intubations performed, with fewer complications occurring in the hands of operators with more awake fibreoptic intubation experience. Our data demonstrate that awake fibreoptic intubation is a safe procedure with a high success rate. Institutional awake fibreoptic intubation training can both develop and maintain trainee competence in performing awake fibreoptic intubation, with a similar incidence of complications and success compared with consultants.
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Affiliation(s)
| | - D N Onwochei
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J Cuddihy
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - I Ahmad
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Xue FS, Liu QJ. Tracheal Intubation Awake or Under Anesthesia for Potential Difficult Airway: Look Before You Leap. Chin Med J (Engl) 2018. [PMID: 29521305 PMCID: PMC5865328 DOI: 10.4103/0366-6999.226891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Fu-Shan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Qian-Jin Liu
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Jiang J, Ma DX, Li B, Wu AS, Xue FS. Videolaryngoscopy versus fiberoptic bronchoscope for awake intubation - a systematic review and meta-analysis of randomized controlled trials. Ther Clin Risk Manag 2018; 14:1955-1963. [PMID: 30410341 PMCID: PMC6197207 DOI: 10.2147/tcrm.s172783] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background Awake intubation with videolaryngoscopy (VL) is a novel method that is drawing more and more attention as an alternative to awake intubation with fiberoptic bronchoscope (FOB). This meta-analysis is designed to determine the performance of VL compared to the FOB for awake intubation. Methods The Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web of science were searched from database inception until October 30, 2017. Randomized controlled trials comparing VL and FOB for awake intubation were selected. The primary outcome was the overall success rate. Rev-Man 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE system was used to assess the quality of evidence for all outcomes. Results Six studies (446 patients) were included in the review for data extraction. Pooled analysis did not show any difference in the overall success rate by using VL and FOB (relative risk [RR], 1.00; P=0.99; high-quality evidence). There was no heterogeneity among studies (I2=0). Subgroup analyses showed no differences between two groups through nasal (RR, 1.00; P=1.00; high-quality evidence) and oral intubations (RR, 1.00; P=0.98; high-quality evidence). The intubation time was shorter by using VL than by using FOB (mean difference, −40.4 seconds; P<0.01; low-quality evidence). There were no differences between groups for other outcomes (P>0.05). Conclusion For awake intubation, VL with a shorter intubation time is as effective and safe as FOB. VL may be a useful alternative to FOB.
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Affiliation(s)
- Jia Jiang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Da-Xu Ma
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Bo Li
- Beijing Hospital of Traditional Chinese Medicine, Affiliated to Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing 100010, China
| | - An-Shi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Fu-Shan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China,
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Schäuble JC, Heidegger T. [Management of the difficult airway : Overview of the current guidelines]. Anaesthesist 2018; 67:725-737. [PMID: 30291405 DOI: 10.1007/s00101-018-0492-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Several national airway task forces have recently updated their recommendations for the management of the difficult airway in adults. Routinely responding to airway difficulties with an algorithm-based strategy is consistently supported. The focus is increasingly not on tools and devices but more on good planning, preparation and communication. In the case of anticipated airway difficulties the airway should be secured when the patient is awake with maintenance of spontaneous ventilation. Unaltered a flexible bronchoscopic intubation technique is advised as a standard of care in such patients. The importance of maintenance of oxygenation is emphasized. Face mask ventilation and the use of supraglottic devices are recommended if unexpected airway difficulties occur. Face mask ventilation may be facilitated and optimised by early administration of neuromuscular blocking agents. If required, in not fastened patients threatened by acute hypoxia, carefully applied and pressure-controlled ventilation may ensure sufficient oxygenation until the airway is secured. Apnoeic oxygen techniques are recommended in high-risk patients and to relieve the time pressure of falling oxygen saturation during decision-making processes. The early use of video laryngoscopy is advised for endotracheal intubation in the case of failed direct laryngoscopy or if intubation is expected to be difficult. For the coverage of cannot intubate-cannot oxygenate scenarios, second generation supraglottic devices and invasive airway access are advocated. The discussion regarding the optimal technique for emergency invasive airway access is still in progress. In the case of uncontrollable respiratory deterioration and progressive hypoxia, the algorithm must be consistently executed and without delay due to ineffective activities (straightforward strategy). Although there is no evidence to support the selection of a particular approach, the importance and the need for a defined airway concept/algorithm in any anesthesia department is fostered. Simplicity and clarity are essential for recall under stressful and time-sensitive conditions. The algorithm should be adapted to local conditions and preferences and devices should be limited to a definite number. The acquisition and maintenance of expertise by education and training is demanded.
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Affiliation(s)
- J C Schäuble
- Institut für Anästhesiologie, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Schweiz.
| | - T Heidegger
- Departement für Anästhesie, Intensivmedizin und Reanimation, Spitalregion Rheintal, Werdenberg, Sarganserland, Schweiz.,Universität Bern, Bern, Schweiz
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Evans SW, McCahon RA. Management of the airway in maxillofacial surgery: part 1. Br J Oral Maxillofac Surg 2018; 56:463-468. [PMID: 29907469 DOI: 10.1016/j.bjoms.2018.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/25/2018] [Indexed: 12/17/2022]
Abstract
In part 1 of this review of management of the airway in maxillofacial surgery we discuss preoperative assessment of the airway, and the practical means to deal with difficulties. We review the evidence for videolaryngoscopy and flexible indirect laryngoscopy, together with surgical access to the airway including tracheostomy, cricothyroidotomy, and submental intubation.
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Affiliation(s)
- S W Evans
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre campus, Derby Road, Nottingham, NG7 2UH
| | - R A McCahon
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre campus, Derby Road, Nottingham, NG7 2UH.
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