A comparison of the Enk Fiberoptic Atomizer Set(™) with boluses of topical anaesthesia for awake fibreoptic intubation

Subglottic spray via epidural catheter in awake tracheal intubation: A CARE-compliant case report

RATIONALE

For anticipated difficult airways, awake tracheal intubation is strongly recommended by guidelines for its high success rate and safety. The key to successful awake tracheal intubation is effective airway topicalization. Currently available topicalization techniques have corresponding drawbacks and complications. Especially for subglottic topicalization, noninvasive techniques are not effective. Subglottic spray via epidural catheter with a flexible bronchoscope provided an effective and noninvasive technique.

PATIENT CONCERNS

A 73-year-old female patient with a history of giant goiter for 9 years suffered chest tightness and shortness of breath, and a 54-year-old male patient with a neck mass and hoarseness were scheduled for thyroidectomy.

DIAGNOSES

Two cases of anticipated difficult airway due to compression by a giant goiter.

INTERVENTIONS

The subglottic area was topicalized via an epidural catheter with a flexible bronchoscope, and awake tracheal intubation was successfully performed.

OUTCOMES

This technique was effective in eliminating airway reactions and hemodynamic fluctuations during awake intubation and improving the intubation success rate and patient tolerance.

LESSONS

This is the first report of subglottic topicalization via an epidural catheter with a flexible bronchoscope applied in cases of awake intubation in giant goiter. The epidural catheter spray is safe and effective in awake intubation of an anticipated difficult airway, and this noninvasive technique is an alternative option to transtracheal injection.

Effects of Lidocaine Oropharyngeal Spray Applied Before Endotracheal Intubation on QT Dispersion in Patients Undergoing Coronary Artery Bypass Grafting: A Prospective Randomized Controlled Study

OBJECTIVE

To investigate the effects of lidocaine oropharyngeal spray applied before endotracheal intubation on hemodynamic responses and electrocardiographic parameters in patients undergoing coronary artery bypass grafting.

METHODS

A total of 60 patients who underwent coronary artery bypass grafting surgery were included in this prospective randomized controlled study. Patients were randomly divided into two groups, the topical lidocaine group (administration of 10% lidocaine oropharyngeal spray, five minutes before laryngoscopy and endotracheal intubation) and the control group. Both groups were compared with each other in terms of main hemodynamic parameters including mean arterial pressure and heart rate, as well as P and QT wave dispersion durations, before and after endotracheal intubation.

RESULTS

The groups were similar in terms of age, gender, and other demographics and basic clinical characteristics. There was a statistically significant difference between the groups in terms of QT dispersion durations after laryngoscopy and endotracheal intubation. The increase in QT dispersion duration was not statistically significant in the topical lidocaine group, whereas the increase in QT dispersion duration was statistically significant in the control group. When the groups were compared in terms of P wave dispersion durations, there were significant decreases in both groups, but there was no significant difference between the groups.

CONCLUSION

Our study revealed that the topical lidocaine administration before endotracheal intubation prevented increase of QT dispersion duration in patients undergoing coronary artery bypass grafting.

TRIAL REGISTRATION

NCT03304431.

Nebulization versus standard application for topical anaesthesia during flexible bronchoscopy under moderate sedation - a randomized controlled trial

Background

Endobronchial administration of lidocaine is commonly used for cough suppression during diagnostic bronchoscopy. Recently, nebulization of lidocaine during bronchoscopies under deep sedation with fiberoptic intubation using a distinct spray catheter has been shown to have several advantages over conventional lidocaine administration via syringe. However, there are no data about this approach in bronchoscopies performed under moderate sedation. Therefore, this study compared the tolerability and safety of nebulized lidocaine with conventional lidocaine administration via syringe in patients undergoing bronchoscopy with moderate sedation.

Methods

Patients requiring diagnostic bronchoscopy were randomly assigned to receive topical lidocaine either via syringe or via nebulizer. Endpoints were consumption of lidocaine and sedative drugs, as well as patient tolerance and safety.

Results

Sixty patients were included in the study (n = 30 in each group). Patients required lower doses of endobronchial lidocaine when given via nebulizer versus syringe (164.7 ± 20.8 mg vs. 250.4 ± 42.38 mg; p < 0.0001) whereas no differences in the dosage of sedative drugs were observed between the two groups (all p > 0.05). Patients in the nebulizer group had higher mean oxygen saturation (96.19 ± 2.45% vs. 94.21 ± 3.02%; p = 0.0072) and a lower complication rate (0.3 ± 0.79 vs. 1.17 ± 1.62 per procedure; p = 0.0121) compared with those in the syringe group.

Conclusions

Endobronchial lidocaine administration via nebulizer was well-tolerated during bronchoscopies under moderate sedation and was associated with reduced lidocaine consumption, a lower complication rate and better oxygenation compared with lidocaine administration via syringe.

Trial registration

The study was registered with clinicaltrials.gov (NCT02262442; 13^th October 2014).

Electronic supplementary material

The online version of this article (10.1186/s12931-018-0926-5) contains supplementary material, which is available to authorized users.

Topical Airway Anesthesia for Awake-endoscopic Intubation Using the Spray-as-you-go Technique with High Oxygen Flow

A patient's willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can jeopardize their spontaneous breathing, topical anesthesia of the airway is a popular technique. The spray-as-you-go technique represents one of the simplest opportunities to anesthetize the airway mucosa. The application of local anesthetic through the working channel of the flexible endoscope is a widespread practice for anesthetists as well as pulmonologists. There is neither need for additional devices nor special training as a pre-requisite to perform this technique. However, a known clinical problem is the coughing and gagging reflex that may occur when the liquid anesthetic strikes the airway mucosa and other sensitive structures like the vocal cords. This can be avoided by the use of oxygen applied through the working channel with the aim of fogging the local anesthetic into finer particles. Furthermore, the oxygen flow provides a higher oxygen supply and contributes to a better view, dispersing mucus secretions and blood away from the lens. Using an atomizer with a high oxygen flow of 10 L/min we maximized these benefits, caused less coughing and had more satisfied and therefore cooperative patients. Possible, but very rare complications of using oxygen flow including gastric insufflation, organ rupture or barotrauma did not arise. We attribute the complication-free use of high oxygen flow to the design of the set, which permits flow and pressure release.

Efficacy of atomised local anaesthetic versus transtracheal topical anaesthesia for awake fibreoptic intubation

BACKGROUND AND AIMS

Successful awake fibreoptic intubation (AFOI) depends on adequate topical anaesthesia of the airway. We aimed to compare efficacy of atomised local anaesthetic versus transtracheal topical anaesthesia for AFOI.

METHODS

It was a prospective, randomised controlled study of 33 patients with the American Society of Anesthesiologists' physical status 1-3 with anticipated difficult airway requiring AFOI. The primary objective was to compare the patient comfort after topical anaesthesia of the airway using atomiser with transtracheal injection of the local anaesthetic agent for AFOI in patients with anticipated difficult airway. The secondary objectives were to compare the ease of intubation, time required to intubate and the haemodynamic changes during intubation. After topical anaesthesia of nostrils, patients in Group T received transtracheal injection of 4 ml of 4% lignocaine whereas Group A patients received 4-5mL of 4% atomised lignocaine using DeVilbiss atomiser before AFOI. Patient comfort assessed objectively by the anaesthetic assistant during the procedure, ease of intubation assessed using cough and gag reflex score, time taken to intubate and the haemodynamic changes during the procedure were compared.

RESULTS

Ease of intubation, patient comfort and the time taken to intubate were significantly better in Group T patients, with P = 0.001, 0.009 and 0.019, respectively, compared with the patients in Group A. There were no significant changes in haemodynamic parameters.

CONCLUSION

Topical anaesthesia by transtracheal injection in patients with anticipated difficult airway made AFOI easier and faster with better patient comfort compared to atomiser with no clinically significant untoward side effects.