Awake nasotracheal intubation with a 300-mm working length fiberscope: a prospective observational feasibility trial
Intubação nasotraqueal do paciente acordado com um fibroscópio de 300 mm de comprimento de trabalho: um estudo de viabilidade observacional prospectivo
Ioan Florin Marchis, Claudiu Zdrehus, Sever Pop, Doinel Radeanu, Marcel Cosgarea, Calin Iosif Mitre
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.
Keywords
Resumo
Introdução
A intubação traqueal com fibra óptica do paciente acordado é um método estabelecido para proteger vias aéreas difíceis, mas há algumas reservas sobre seu uso porque muitos profissionais consideram-no tecnicamente complicado, demorado e desagradável para os pacientes. Nosso principal objetivo foi testar a segurança e eficácia de um fibroscópio de comprimento útil de 300 mm (videorinolaringoscópio) quando usado para intubação nasotraqueal acordado em casos de vias aéreas difíceis.
Métodos
Este foi um estudo prospectivo, unicêntrico, envolvendo pacientes adultos, com estado físico ASA entre I e IV, com patologia laringofaríngea causando anatomia distorcida das vias aéreas. A intubação nasotraqueal acordada, com anestesia tópica e sedação leve, foi realizada com fibroscópio de 300 mm de comprimento e 2,9 mm de diâmetro equipado com tubo endotraqueal reforçado lubrificado. Os resultados primários foram o sucesso e a duração do procedimento. A satisfação periprocedimento dos pacientes e outros incidentes foram registrados.
Resultados
Intubamos com sucesso todos os 25 pacientes incluídos neste estudo. A duração média ± DP do procedimento, desde a passagem do tubo de intubação por uma das narinas até a intubação endotraqueal, foi de 76 ± 36 segundos. A maioria dos pacientes não apresentou desconforto durante o procedimento com significância estatística entre o Grupo Sem reação com o Grupo Careta Leve (IC95% 0,13; 0,53, p = 0,047) e o Grupo Careta Intensa (IC 95% 0,05; 0,83, p = 0,003). A média ± DP do escore de satisfação 24 horas pós-intervenção foi de 1,8 ± 0,86 – desconforto leve. Não ocorreram incidentes significativos.
Conclusão
Nosso estudo mostrou que um endoscópio flexível de 300 mm de comprimento de trabalho é rápido, seguro e bem tolerado para intubação nasotraqueal acordado sob vias aéreas desafiadoras.
Palavras-chave
References
1 LH Lundstrøm, CV Rosenstock, J Wetterslev, et al. The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patients Anaesthesia, 74 (2019), pp. 1267-1276
2 W Rosenblatt, AI Ianus, W Sukhupragarn, et al. Preoperative Endoscopic Airway Examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation Anesth Analg, 112 (2011), pp. 602-607
3 JL Apfelbaum, CA Hagberg, RA Caplan, et al. Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway Anesthesiology, 118 (2013), pp. 251-270
4 RA Strauss, R. Noordhoek Management of the difficult airway Atlas Oral Maxillofac Surg Clin North Am, 18 (2010), pp. 11-28
5 JA Law, IR Morris, PA Brousseau, et al. The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: a historical cohort study Can J Anaesth, 62 (2015), pp. 736-744
6 K El-Boghdadly, DN Onwochei, J Cuddihy, et al. A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre Anaesthesia, 72 (2017), pp. 694-703
7 SS Moorthy, S Gupta, B Laurent, et al. Management of airway in patients with laryngeal tumours J Clin Anesth, 17 (2005), pp. 604-609
8 TM Cook, N Woodall, C. Frerk Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia Br J Anaesth, 106 (2011), pp. 617-631
9 E Fitzgerald, I Hodzovic, AF. Smith ‘From darkness into light’: time to make awake intubation with videolaryngoscopy the primary technique for an anticipated difficult airway? Anaesthesia, 70 (2015), pp. 387-392
10 S Alvi, P. Harsha Flexible Nasopharyngoscopy StatPearls Publishing (2020) [Updated 2020 Apr 27]. In: StatPearls [Internet]. Treasure Island (FL)Jan-. Available from https://www.ncbi.nlm.nih.gov/books/NBK539740/
11 BC Paul, B Rafii, S Achlatis, et al. Morbidity and patient perception of flexible laryngoscopy Ann Otol Rhinol Laryn, 121 (2012), pp. 708-713
12 NJ. Davis A new fiberoptic laryngoscope for nasal intubation Anesth Analg, 52 (1973), pp. 807-808
13 A Kuriyama, N Umakoshi, R. Sun Prophylactic Corticosteroids for Prevention of Postextubation Stridor and Reintubation in Adults: A Systematic Review and Meta-analysis Chest, 151 (2017), pp. 1002-1010
14 S. Singh Nasal endoscopy prior to nasotracheal intubation Anaesthesia, 57 (2002), pp. 291-292
15 SR Collins, RS. Blank Fibreoptic Intubation: An Overview and Update Respir Care, 59 (2014), pp. 865-880
16 DB Reed, JE. Clinton Proper depth of placement of nasotracheal tubes in adults prior to radiographic confirmation Acad Emerg Med, 4 (1997), pp. 1111-1114
17 LF Cavallone, A. Vannucci Review article: Extubation of the difficult airway and extubation failure Anesth Analg, 116 (2013), pp. 368-383
18 SA Billingham, AL Whitehead, SA. Julious An audit of sample sizes for pilot and feasibility trials being undertaken in the United Kingdom registered in the United Kingdom Clinical Research Network database BMC Med Res Methodol, 13 (2013), p. 104
19 TT Joseph, JS Gal, S DeMaria, et al. A Retrospective Study of Success, Failure, and Time Needed to Perform Awake Intubation Anesthesiology, 125 (2016), pp. 105-114
20 T; Asai, K. Shingu Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions Br J Anaesth, 92 (2004), pp. 870-881
21 J Jiang, DX Ma, B Li, et al. Videolaryngoscopy versus fiberoptic bronchoscope for awake intubation - a systematic review and meta-analysis of randomized controlled trials Ther Clin Risk Manag, 14 (2018), pp. 1955-1963
22 I Ahmad, K El-Boghdadly, R Bhagrath, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults Anaesthesia, 75 (2020), pp. 509-528
23 N Lages, D Vieira, J Dias, et al. Ultrasound guided airway access Brazilian Journal of Anesthesiology, 68 (2018), pp. 624-632
24 A Kramer, D Muller, R Pfortner, et al. Fibreoptic vs videolaryngoscopic (C-MAC® D-BLADE) nasal intubation under local anaesthesia Anaesthesia, 70 (2015), pp. 400-406
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