Comparative evaluation of nebulized versus intravenous dexmedetomidine on intubating conditions during awake fiberoptic nasotracheal intubation

BACKGROUND

There is a search for an ideal agent to facilitate awake fiberoptic intubation (AFOI). Dexmedetomidine is a selective α2 agonist which can be administered through intravenous, intramuscular, buccal, intranasal & inhalational routes. It provides good intubation conditions without oxygen desaturation but may cause hypotension and bradycardia when administered intravenously. Hence, alternative routes of administering dexmedetomidine which may improve its safety profile are worth exploring.

METHODS

In this randomised, controlled, double-blind trial, 46 ASA I/II adult participants scheduled for elective ENT surgery were randomly allocated to Group ND (Nebulised Dexmedetomidine) (n = 23) to receive nebulisation with dexmedetomidine 1μg.kg-1 and Group ID (Intravenous Dexmedetomidine) (n = 23) to receive intravenous dexmedetomidine 1μg.kg-1 before AFOI. All the patients received injection midazolam 1 mg i.v. as premedication before anaesthesia was initiated. The primary outcome was the cough score. The secondary outcomes were the RSS, SAYGO boluses, post-intubation score, hemodynamic parameters, recall of the procedure, patient satisfaction score and any side effects.

RESULTS

The cough score was significantly lower in nebulized group (2.43 ± 0.992 vs 3.52 ± 1.082) with p = 0.001. RSS(3.30 ± 0.926 vs 4.22 ± 1.126; p = 0.004), number of SAYGO boluses required (2.74 ± 0.864 vs 3.57 ± 1.161; p = 0.009) & the post intubation score (1.48 ± 0.593 vs 2.17 ± 0.778; p = 0.001) were also significantly lower in nebulized group.

CONCLUSIONS

Nebulisation with dexmedetomidine results in desirable degree of sedation and better tolerance of the procedure with adequate attenuation of the haemodynamic responses to intubation.

Airway Considerations in Vascular Lesions

Vascular anomalies of the head and neck frequently involve the upper aerodigestive tract and can cause some level of airway obstruction. It is important to fully evaluate the extent of a lesion and resultant functional impairment with a flexible fiberoptic laryngoscopy. Treating these lesions is difficult and considering how to manage the airway during a procedure is critical. A multidisciplinary approach should be used for airway management with alternative intubation plans established prior to induction of anesthesia. Edema and hemorrhage are expected complications from the treatment of vascular anomalies and should be considered when planning for extubation at the end of a procedure.

Anaesthetic Management of a Child with Parapharyngeal Abscess

Airway management in a case of parapharyngeal abscess is challenging as there can be airway obstruction during anaesthetic induction. We describe airway management in 13-yr-old child with parapharyngeal abscess scheduled for incision and drainage. Informed consent was taken for publishing this case report.

Anaphylaxis: Emergency Department Treatment

Anaphylaxis is a potentially life-threatening, multisystem allergic reaction that can cause airway, breathing, or circulatory compromise. Intramuscular epinephrine is the immediate treatment of all patients. Intravenous epinephrine should be used in patients in shock, either as a bolus or infusion, along with fluid resuscitation. Airway obstruction must be recognized, and early intubation may be necessary. For shock that is refractory to epinephrine, additional vasopressors may be needed. Disposition depends on patient presentation and response to treatment. Mandatory observation periods are not necessary, because biphasic reactions are difficult to predict and may occur outside of typical observation periods.

Anaphylaxis: Emergency Department Treatment

Anaphylaxis is a potentially life-threatening, multisystem allergic reaction that can cause airway, breathing, or circulatory compromise. Intramuscular epinephrine is the immediate treatment of all patients. Intravenous epinephrine should be used in patients in shock, either as a bolus or infusion, along with fluid resuscitation. Airway obstruction must be recognized, and early intubation may be necessary. For shock that is refractory to epinephrine, additional vasopressors may be needed. Disposition depends on patient presentation and response to treatment. Mandatory observation periods are not necessary, because biphasic reactions are difficult to predict and may occur outside of typical observation periods.

Comparison between Intravenous Dexmedetomidine and Spray as you Go with 4% Lignocaine Versus Intravenous Fentanyl and Transtracheal Injection of 4% Lignocaine for Awake Nasotracheal Intubation with Flexible Vedioscope - A Randomized Single-Blind Prospective Study

Background:

Awake fiber-optic bronchoscopy-guided intubation is the method of choice in difficult airway which requires effective airway anesthesia to ensure patient comfort and acceptance.

Aims:

This study was conducted to assess the quality of airway anesthesia, patient comfort during intubation, and postoperative satisfaction of patients.

Settings:

Patients posted for surgeries under general anesthesia with Mallampati Grade I and II in a medical college. Patients were followed in the operation theater and postoperative ward.

Study Design:

This was a prospective randomized single-blind study.

Materials and Methods:

Group D received intravenous (i.v.) dexmedetomidine 1 μg.kg⁻¹ i.v. over 10 min and 3 ml of 4% lignocaine spray as you go (SAYGo). Group F received i.v. fentanyl 2 μg.kg⁻¹ over 10 min and transtracheal injection 3 ml of 4% lignocaine. Parameters assessed were endoscopic time, intubating condition, vocal cord position, cough severity, comfort during intubation, postoperative patient satisfaction, and any adverse effects such as sore throat, hoarseness, unpleasant memories, and hemodynamic response during intubation.

Statistical Analysis:

Independent Student's t-test, Mann–Whitney, Chi-squared test, or Fisher's exact test were used. P ≤ 0.05 was considered statistically significant.

Results:

Intubating conditions, vocal cord position, cough severity, comfort during intubation, and postoperative patient satisfaction were statistically significant (P ≤ 0.05) in favor of Group D though endoscopic time was longer.

Conclusion:

IV dexmedetomidine with SAYGo is effective than IV fentanyl with transtracheal block for awake fiber-optic videoscopic intubation in terms of intubating conditions, vocal cord position, cough severity, comfort during intubation, and postoperative satisfaction of patients with significant attenuation of postintubation hemodynamic response and better preservation of respiration though endoscopic time is more.

Evaluation of retrograde intubation with different doses of dexmedetomidine infusion: A randomised controlled trial

Background

Retrograde intubation is one of the well-described and alternative methods of difficult airway management. It requires effective sedation and patient preparation. Study was done to evaluate intubating conditions during retrograde guided intubation with two different doses of dexmedetomidine.

Methods

This prospective randomized double blind parallel group trial was planned on 60 patients with difficult airway. Patients were divided in two groups to receive either dexmedetomidine 1.0 μg/kg (Group A) or dexmedetomidine 1.5 μg/kg (Group B) by intravenous (IV) route. The Modified Observer Assessment Awareness and Sedation (OAA/S) was measured as primary outcome and ease of intubation, facial grimace score, cough severity, hemodynamic response, patient recall and discomfort were assessed as secondary outcome during awake retrograde intubation.

Results

Groups were comparable in terms of demographic and baseline parameters. OAA/S (P = 0.001), cough severity (P < 0.001), facial grimace score (P < 0.001), grading of discomfort during procedure (P < 0.001) and recall of procedure scale (P = 0.038) were found significantly better/lower in Group B as compared to Group A. Hemodynamic parameters were better in Group B and showed significant difference during the retrograde intubation. However, ease of intubation scale, intubating time and complications were not significantly different (P > 0.05) between the two groups.

Conclusion

Retrograde intubation can be easily learned and performed with minimal complications. Dexmedetomidine in a dose of 1.5 μg/kg IV is optimum and safe for retrograde intubation with clinically manageable side effects.

Awake intubation and extraluminal use of Uniblocker for one-lung ventilation in a patient with a large mediastinal mass a case report

Background

The anesthesia of patients with large mediastinal mass is at high-risk. Avoidance of general anesthesia in these patients is the safest option, if this is unavoidable, maintenance of spontaneous ventilation is the next safest technique. In these types of patients, it is not applicable to use double-lumen tube (DLT) to achieve one-lung ventilation (OLV) because the DLT has a larger diameter and is more rigid than single-lumen tube (SLT), so the mass may rupture and bleed during intubation. Even using a bronchial blocker, a small size of SLT is required for once the trachea collapses the SLT can pass through the narrowest part of trachea. However, it is difficult to control the fiberoptic bronchoscopy (FOB) and the bronchial blocker simultaneously within the lumen of a small size SLT with traditional intubation methods.

Case presentation

The current study presented a 66 years old female patient with a large mediastinal mass that presented with difficulty breathing when lying flat. In this case, we combined use of dexmedetomidine and remifentanil to preserve the patient’s spontaneous ventilation during intubation and achieved one-lung ventilation with extraluminal use of Uniblocker.

Conclusions

Extraluminal use of Uniblocker and maintenance of spontaneous ventilation during intubation may be an alternative to traditional methods of lung isolation in such patients with a large mediastinal mass.

The High-Risk Airway

The high-risk airway is a common presentation and a frequent cause of anxiety for emergency physicians. Preparation and planning are essential to ensure that these challenging situations are managed successfully. Difficult airways typically present as either physiologic or anatomic, each type requiring a specialized approach. Primary physiologic considerations are oxygenation, hemodynamics, and acid-base, whereas anatomic difficulty is overcome using proper positioning and skilled laryngoscopy to ensure success. It is essential to be comfortable performing alternative techniques to address varying presentations. Ultimately, competence in airway management hinges on consistent training, deliberate practice, and a dedication to excellence.

Awake fiberoptic intubation with an epidural catheter in a morbidly obese patient

We report successful awake intubation in a morbidly obese patient (body mass index of 61.2) using an epidural catheter inserted through the external forceps channel of the fiberscope for delivery of local anesthetic. Direct application of local anesthetic to the pharyngolaryngeal area and proximal tracheal, through the use of a relatively firm epidural catheter. We conclude that awake intubation can be achieved by this method which spares the subsequent use of any sedative drugs.

Awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review

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 Auragain^TM 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.

McGrath® videolaryngoscopy in an awake patient with a huge dangling vocal papilloma: a case report

A 68-year-old patient with a huge dangling vocal papilloma was admitted for surgical resection. Preoperative data regarding the patient’s mass-related symptoms, endoscopic view, and radiological evaluation indicated that airway management would be difficult. Fiberoptic intubation has been considered an ideal primary approach to managing problematic airways, but blind advancement of the endotracheal tube without a clear, consistent view of the mass presents a significant threat to patient safety. This report describes how safe intubation was accomplished while the patient was awake using laryngeal nerve blocks and a McGrath® videolaryngoscope.

RETRACTED: Proficiency of Dams Tulip-i® in awake fiberoptic orotracheal intubation for difficult airway

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief as it contains fabricated/falsified data. The Editor-in-Chief decision was based on the investigation by the Japanese Society of Anesthesiologists which concluded that no research was conducted and all the data including patient backgrounds were fabricated. The society also concluded that the corresponding author, Dr. Ueshima presented the names of the individuals not involved or only partially involved in research as lead authors, presented the names of the individuals not involved in research as co-authors and submitted papers without the agreement of the co-authors. The investigation report can be found here.

Can videolaryngoscopy be a first option in a patient with laryngeal amyloidosis?

Amyloidosis is a term that involves a group of diseases characterised by deposition of extracellular monoclonal light-chain fibrillar immunoglobulin aggregates in the body, including many organs, with the larynx among them. A case is presented of a 78 year-old man who was referred to our institution for strangulated umbilical hernia treatment. He suffered from progressive hoarseness and dysphagia for 5months. He had a history of primary laryngeal amyloidosis. Awake intubation was performed successful with the King Vision^® video-laryngoscopy. Sedation was achieved using a remifentanil infusion and midazolam. Haemorrhagic lesions are caused by deposition of amyloid in and around vessels, resulting in increased vascular fragility. Therefore, anaesthetists should take care in intubating the tracheas of these patients.

Dexmedetomidine versus remifentanil for sedation during awake intubation using a Shikani optical stylet: a randomized, double-blinded, controlled trial

Background

The purpose of this study was to compare the efficacy and safety of dexmedetomidine versus remifentanil for sedation during awake intubation using a Shikani optical stylet (SOS).

Methods

Sixty-eight patients with cervical trauma or severe cervical spondylosis undergoing cervical spinal surgery were enrolled in this prospective study. They were randomly assigned to receive dexmedetomidine (Group D) or remifentanil (Group R). In Group D, the patients received an intravenous loading dose of dexmedetomidine 1 μg · kg⁻¹ over 10 min followed by a continuous infusion of 0.7 μg · kg⁻¹ · h⁻¹. In Group R, a target-controlled infusion of remifentanil was administered to achieve a plasma concentration of 2.5 ng · ml⁻¹, increased to 3 ng · ml⁻¹ 10 min later. An endotracheal tube was inserted using a SOS under dexmedetomidine or remifentanil sedation after topical anesthesia to the airway. Midazolam was given as rescue sedation. We recorded the first attempt intubation success rate, the dose of midazolam, duration of intubation, Ramsay Sedation Scale (RSS) score, tracheal tube tolerance score, duration of drug infusion, adverse events and patient satisfaction score.

Results

The RSS score was significantly higher in Group D than in Group R. First attempt success rate, rescue midazolam dose and the duration of intubation did not differ between the groups. Patients in Group R were significantly more tolerant of the tracheal tube. The incidence of hypoxia was significantly higher in Group R than Group D, but there was no significant difference in the incidence of other adverse events between the groups. The hemodynamic responses of the two groups were similar, but more patients in Group R were able to recall airway instrumentation.

Conclusions

Both dexmedetomidine and remifentanil are effective sedatives for awake intubation using an SOS. Although the first attempt success rates were similar, patients sedated with remifentanil tolerated the tracheal tube better after intubation with moderately increased risk of desaturation.

Trial registration

www.chictr.org.cn; ChiCTR-TRC-13003052 (February 4th, 2013).

Awake intubating laryngeal mask airway placement in a morbidly obese patient with ankylosing spondylitis and unstable thoracic spine

Intubating laryngeal mask airways can be used to provide continuous ventilation throughout intubation. This is a case of a morbidly obese (body mass index = 58) 65-year-old woman with T10 and T11 compression fractures. Optimal positioning for airway management was hindered by her unstable spine, minimal neck range of motion, and extreme pain with any movement. An intubating laryngeal mask airway was placed in the awake, topically anesthetized patient, and the laryngeal mask airway and endotracheal tube combination was left in place throughout surgery.

Comparative randomised study of GlideScope® video laryngoscope versus flexible fibre-optic bronchoscope for awake nasal intubation of oropharyngeal cancer patients with anticipated difficult intubation

Background and Aims:

Awake flexible fibre-optic bronchoscope (FFS) is the standard method of intubation in difficult airway in oral cancer patients. We decided to evaluate GlideScope^® video laryngoscope (GL) for intubation as compared to the standard FFS for nasal intubation in such patients.

Methods:

After the ethical committee approval, we included 54 oropharyngeal cancer patients divided randomly into two equal groups: Group G and Group F. After pre-medication and pre-oxygenation, awake nasal intubation was performed using GL in Group G and FFS in Group F. In both groups, we compared intubation time in seconds (mean ± standard deviation) (primary outcome), success rate of the first intubation attempt, percentage of Cormack and Lehane glottic score and incidence of complications. We assumed that GL could be a suitable alternative for the standard FFS in nasal intubation of patients with oropharyngeal cancer. Success rate of the first attempt and Cormack and Lehane glottic score were compared using Chi-square test.

Results:

Intubation time in seconds was significantly shorter in Group G (70.85 ± 8.88 S) than in Group F (90.26 ± 9.41 S) with (P < 0.001). The success rate of the first attempt intubation was slightly higher in Group G (81.5%) than Group F (78.8%). Cormack and Lehane glottic Score I and II showed insignificant difference between both Group G (92.6%) and Group F (96.3%). We detected three cases of sore throat in each group.

Conclusion:

GlideScope^® could be a suitable alternative to FFS in nasal intubation of oropharyngeal cancer patients.

C-MAC® video laryngoscope with D-BLADE™ and Frova introducer for awake intubation in a patient with parapharyngeal mass

Parapharyngeal tumors are rare head and neck tumors which can present as an intraoral mass and can pose great challenge to anesthesiologists. The primary concern is the difficult airway due to gross anatomical distortion of the upper airway. Securing the airway in an awake state should be the primary goal of anesthesiologists to avoid catastrophic complications. Herewith, we report the successful use of C-MAC^® video laryngoscope with the acute-angle D-BLADE™ in combination with Frova introducer for awake intubation in a patient with parapharyngeal mass after multiple attempts of failed fiber-optic intubation.

Difficult airway management in a patient with a parapharyngeal tumor

A 47-year-old man was referred to the operating room to treat a dentigenous cyst of the mandibular bone. Initial assessment of the airway was considered normal. However, after the induction of anesthesia, we could not intubate the patient due to severe distortion of the glottis. Fiberoptic bronchoscopy and video laryngoscopy were not effective. Intubation using a retrograde wire technique was successful. After the conclusion of surgery, the patient recovered without any complications. Subsequent magnetic resonance imaging of the patient's neck showed a 6 × 4 × 8.6 cm heterogeneous T2 hyperintense, T1 isointense well-enhancing mass in the prestyloid parapharyngeal space. The patient was scheduled for excision of the mass. We planned awake intubation with fiberoptic bronchoscopy. The procedure was successful and the patient recovered without complications. Anesthetic induction can decrease the muscle tone of the airway and increase airway distortion. Therefore, careful airway assessment is necessary.

Giant fibrovascular polyp on aryepiglottic fold

Polyps are common lesions in pharynx and larynx. A 46-year-old woman was transferred to our department because of the huge laryngeal mass, which was incidentally detected during routine health screening. On laryngoscopic exam, both vocal folds were not visualized due to the mass but she had no symptom such as hoarseness, dysphagia, and dyspnea. Awake intubation was safely performed using flexible bronchoscope without tracheostomy. A 4-cm sized mass on the left aryepiglottic fold was removed with trans-oral approach and discharged without complication. The pathologic diagnosis was reported as 'fibrovascular polyp'. Herein, we describe a unique case of giant fibrovascular polyp on aryepiglottic fold, which is the first report in the English literature.

Airway anesthesia: theory and practice

Topical anesthesia of the airway is a necessary for awake intubation and is usually achieved using lidocaine delivered by various means. Although some experts favor the use of airway blocks, a more common approach is to use pure topical methods in combination with "spray as you go" techniques. Once the topicalization is complete, the patient should be able to easily tolerate the use of an oral airway used to facilitate awake oral intubation. Nasal intubation requires additional topicalization of the nasal passages in conjunction with a vasoconstrictor. Finally, judicious sedation is frequently used when awake intubation is carried out.

Comparison between dexmedetomidine and fentanyl on intubation conditions during awake fiberoptic bronchoscopy: A randomized double-blind prospective study

Background and Aims:

Various drugs are used for providing favorable intubation conditions during awake fiberoptic intubation (AFOI). However, most of them cause respiratory depression and airway obstruction leading to hypoxemia. The aim of this study was to compare intubation conditions, and incidence of desaturation between dexmedetomidine and fentanyl group during AFOI.

Material and Methods:

This randomized double-blind prospective study was conducted on a total of 60 patients scheduled for elective laparotomies who were randomly allocated into two groups: Group A received dexmedetomidine 1 mcg/kg and Group B received fentanyl 2 mcg/kg over 10 min. Patients in both groups received glycopyrrolate 0.2 mg intravenous, nebulization with 2% lidocaine 4 ml over 20 min and 10% lidocaine spray before undergoing AFOI. Adequacy of intubation condition was evaluated by cough score and post-intubation score. Incidence of desaturation, hemodynamic changes and sedation using Ramsay sedation scale (RSS) were noted and compared between two groups.

Results:

Cough Score (1-4), post-intubation Score (1-3) and RSS (1-6) were significantly favorable (P < 0.0001) along with minimum hemodynamic responses to intubation (P < 0.05) and less oxygen desaturation (P < 0.0001) in Group A than Group B.

Conclusion:

Dexmedetomidine is more effective than fentanyl in producing better intubation conditions, sedation along with hemodynamic stability and less desaturation during AFOI.

Emergency thyroidectomy: Due to acute respiratory failure

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CT scan has a great value for retrosternally extended giant goiter cases.

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If the general status of the patient prevents CT scan, bedside ultrasound can be used instead.

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Nasal awake intubiation is an appropriate choice for the patients with destructed trachea.

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Emergency thyroidectomy is a common option for the treatment of giant goiter causing airway obstruction.

INTRODUCTION

Giant cervical and mediastinal goiter may lead to acute respiratory failure caused by laryngotracheal compression and airway obstruction. Here, we present a case admitted to the emergency service with a giant goiter along with respiratory failure and poor general health status, which required urgent surgical intervention.

PRESENTATION OF CASE

A 71-year-old female admitted to the emergency room with shortness of breath and poor general health status resulting from a giant cervical swelling progressively increased during the last 7 years and constituted severe respiratory failure which has become severe in the last one month. A giant nodular goiter of the left thyroid lobe extending retrosternally, causing tracheal compression, limiting the neck movements was detected with clinical examination and bedside ultrasound. Emergency thyroidectomy was planned. Fiberoptic-assisted awake nasal intubation was performed in the operating room. Emergency total thyroidectomy was performed for the life-threatening respiratory failure. Postoperative period was uneventful. She was transferred from intensive care unit to the ward on postoperative day 3 and was discharged from the hospital on the postoperative 7th day. Benign multinodular hyperplasia was reported on the histopathological report. Patient was included in routine follow-up.

DISCUSSION

In the present case tracheal destruction due to compression of the giant goiter was found in agreement with previous reports. Emergency thyroidectomy was performed after awake intubation since it is a common surgical option for the treatment of giant goiter causing severe airway obstruction.

CONCLUSION

Respiratory failure due to giant nodular goiter is a life-threatening situation and should be treated immediately by performing awake endotracheal intubation following emergency total thyroidectomy.

Preparation of the patient and the airway for awake intubation

Awake intubation is usually performed electively in the presence of a difficult airway. A detailed airway examination is time-consuming and often not feasible in an emergency. A simple 1-2-3 rule for airway examination allows one to identify potential airway difficulty within a minute. A more detailed airway examination can give a better idea about the exact nature of difficulty and the course of action to be taken to overcome it. When faced with an anticipated difficult airway, the anaesthesiologist needs to consider securing the airway in an awake state without the use of anaesthetic agents or muscle relaxants. As this can be highly discomforting to the patient, time and effort must be spent to prepare such patients both psychologically and pharmacologically for awake intubation. Psychological preparation is best initiated by an anaesthesiologist who explains the procedure in simple language. Sedative medications can be titrated to achieve patient comfort without compromising airway patency. Additional pharmacological preparation includes anaesthetising the airway through topical application of local anaesthetics and appropriate nerve blocks. When faced with a difficult airway, one should call for the difficult airway cart as well as for help from colleagues who have interest and expertise in airway management. Preoxygenation and monitoring during awake intubation is important. Anxious patients with a difficult airway may need to be intubated under general anaesthesia without muscle relaxants. Proper psychological and pharmacological preparation of the patient by an empathetic anaesthesiologist can go a long way in making awake intubation acceptable for all concerned.

Local Anaesthesia for Fiberoptic Intubation : A Comparison of Three Techniques

BACKGROUND

The successful conduct of fiberoptic aided intubation is dependent upon effective local anaesthesia. The aim of the study was to compare three different methods of anaesthetizing the airway.

METHODS

60 adult patients (American Society of Anaesthesiologists status I-III and Mallampati class III & IV), scheduled for elective surgery, received sedation followed by spraying of the nares and posterior pharyngeal wall with 4% lignocaine. Thereafter the patients received 4 ml of 4% lignocaine either by transtracheal injection (n=20, group A), via intubating fiberscope (Pentax F1-10P2) using 'spray as you go' technique (n=20, group B) or by nebulizer (Devilbiss 5610W) 20 min before intubation, (n=20, group C). Patients were asked to score the procedure using visual analog scale (VAS) and severity scores. Episodes of coughing, choking, stridor, extra / total local anaesthetic used and intubation times were recorded. Patients were monitored continuously for vital parameters.

RESULTS

Group B patients showed better VAS scores with shorter intubation times and had a lower incidence of coughing and choking. The endoscopists' VAS scores also showed a preference for group B.

CONCLUSION

In conclusion the 'spray as you go' technique was safe, provided effective local anaesthesia and was preferred by both patients and endoscopists.

Awake Blind Nasotracheal Intubation in Temporomandibular Joint Ankylosis Patients under Conscious Sedation Using Fentanyl and Midazolam

BACKGROUND AND OBJECTIVES

Intubating a patient with temporomandibular joint ankylosis is always a challenge particularly when fibreoptic laryngoscope is not available. Awake blind nasotracheal intubation requires sufficient patient co operation and comfort. Presently available short-acting analgesics and amnesics are excellent choices for this exercise.

STUDY DESIGN

This prospective randomized double blind study was designed to determine an appropriate dosage of fentanyl for awake blind nasotracheal intubation. We compared two different dosage of fentanyl. Eighty patients were randomly assigned to receive midazolam 0.05 mg/kg and fentanyl 2μg/kg in bolus (group I), or midazolam 0.05 mg/kg, fentanyl 3μg/kg in bolus (group II).

RESULTS

Both dosage regimen ensured patient comfort and sedation. Patients in group II were more calm and sedated as compared to group I. Hemodynamics was also more stable in group II.

CONCLUSION

For awake blind nasotracheal intubation, we therefore recommend midazolam 0.05mg/kg plus fentanyl 3μg/kg in bolus.

Regional & topical anaesthesia of upper airways

SUMMARY

A combination of techniques are required to adequately anaesthetise upper airway structures for awake intubation. The widest coverage is provided by the inhalational technique. This technique, however, does not always provide a dense enough level of anaesthesia for all patients. Supplementation of this technique with any of the specific nerve blocks is an excellent way to accomplish efficacious anaesthesia for awake inubation. Anaesthetising upper airway is not a difficult skill to master and should be in the armamentarium of all practising anaesthetist.

Endotracheal intubation in a patient with an almost complete obstruction of the glottis due to a movable supraglottic tumor: A case report

Intubation in patients with an obstruction of the glottis due to a large mass may present great challenge to most anesthesiologists. If tracheostomy is not available, flexible fiberscope guided endotracheal intubation is now the part of the standard management in these cases, but difficulty in advancing the tracheal tube over the fiberscope and into the trachea may be encountered. In this case, a 60-year-old male with a huge supraglottic mass was given general anesthesia for laryngomicroscopic surgery and debulking of the mass lesion. We planned an awake flexible fiberoptic intubation but failed to railroad the tube over the fiberscope even after successfully placing the scope inside the trachea. During various attempts to pass the tracheal entrance, the patient coughed and the tube slid into the trachea as mass moved aside and we could successfully secure the airway.