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Abstract: Objective: Anesthesia of patient for direct laryngoscopy (DL) and microlaryngosurgery (MLS) was technically challenging. The anesthetist had usually concern about the loss of spontaneous ventilation and occurrence of obstruction after induction with IV drugs. The aim of this study was to compare between flexible fibro-optic bronchoscope and direct rigid laryngoscope during awake intubation in patients with laryngeal mass scheduled for direct laryngoscopic surgery (DL) and microlaryngosurgery (MLS). It was a study to assess the best way for intubation with the least side effects, discomfort to the patients and high success rate of intubation. Methods: Fourty adult patients Malampati 1,2 and ASA I,II,III with small laryngeal mass or polyp scheduled for direct laryngoscope (DL) and microlaryngoscopic surgery. They were randomly computerized divided into two groups 20 patients in each group; Group FO; intubation with flexible fibro-optic bronchoscope. Group RL; intubation with rigid laryngoscope. Results: The time of intubation was statistically significantly higher in fibro-optic group (group FO) (92±34s) than rigid laryngoscope group (group RL) (35±5s). There were two patients in group RL needed 2nd intubation attempt for better visualization of the view but there were six patients in group FO needed 2nd intubation attempt for suction of secretion and blood. According to modified six point scale the patients ranged between 1 and 3 in group FO while they range between 2 and 4 in group RL. Conclusion: The study suggested that the flexible fibro-optic bronchoscope was very comfortable to the patients and less traumatic with less cardiovascular stress but it took longer time and had a higher incidence of 2nd attempt and failure rate. Accordingly, it recommend the use of flexible fibro-optic bronchoscope in expected small size and non-bloody mass with prepared rigid laryngoscope and tube with stylet to be ready to use if needed. [Copyright &y& Elsevier]

Difficult airway management remains central to anes-thesia practice. Video laryngoscopes have been an adjunct to airway management since the early 2000s. They have been shown to improve visualization of the glottic opening and have become a useful aid in managing difficult airways. To date, the preferred method for difficult airway management remains awake fiberoptic intubation. The purpose of this article is to summarize the use of a video laryngoscope for an awake intubation and to suggest alternative uses of these devices in other awake intubation scenarios. The case report presented offers a description of successful awake intubation using a video laryngoscope in a patient with a large pedunculated mass arising from the nasopharynx and extending down into the oropharynx. [ABSTRACT FROM AUTHOR]

Abstract: Background: The Gldiescope video laryngoscope (GVL) as a recent intubating device has gained much popularity in difficult intubation over the last decade. It can be used as a substitute to flexible fiber optic bronchoscope (FOB) in intubating challenges. The object of this study is to compare the utility of GVL and FOB for intubating time, attempts, effects on hemodynamics, adverse effects, patient satisfaction and post intubation neurological outcome during awake intubation in traumatic cervical spine injury. Methods: Fifty patients undergoing post traumatic cervical spine fixation under general anesthesia were randomly allocated to two groups in a prospective, controlled non-blinded study. All patients were premedicated with glycopyrrolate 0.2mg iv and midazolam 1mg iv that be repeated up to 0.05mg/kg followed with a bolus dose of remifentanil 1.5μg/kg then a continuous remifentanil infusion of 0.15μg/kg/min for 3min before procedure. Each patient underwent a wake endotracheal intubation with either GVL (G group) or FOB (F group) with manual in line stabilization (MILS). Intubating time, intubating attempts, hear rate (HR), mean arterial pressure (MAP), oxygen desaturation (SO2 <90%), sore throat, patient satisfaction and postintubation neurological outcome were recorded. Results: Intubating time was significantly lower in G group compared with F group (26±5 versus 72±11 respectively), while the percentage of the first successful intubating attempt was insignificantly higher in G group (88%) than in F group (72%). Both HR and MAP were significantly increased only in F group during intubation in comparison with the basal line values. Both devices were safe for post neurological outcome. No significant differences of adverse effects or patient satisfaction were recorded between groups. Conclusion: The GVL is a safe surrogate for FOB during awake intubation for post traumatic cervical spine fixation. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 37-year-old woman with a body mass index (BMI) of 89 presented for a laparoscopic gastric bypass procedure. It describes the use of airway management to treat the obesity of the patient, including the preparation for the surgery. It reveals that the patient in the case study was maintained a 45° head-of-bed elevated position to maximize her pulmonary function.

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Peripartum cardiomyopathy is a potentially fatal form of heart failure associated with pregnancy. A 29-year-old African American woman, gravida 3, para 2, at 36 weeks' gestation had a history of cardiomyopathy, morbid obesity (body mass index> 70 kg/m²), uncontrolled hypertension, obstructive sleep apnea, and required a repeat cesarean delivery. The patient was admitted to the hospital several times throughout her pregnancy for congestive heart failure, pulmonary edema, and headaches. Two years previously the patient received a diagnosis of peripartum cardiomyopathy 3 weeks after the delivery of her second child. This case report illustrates the recognition of peripartum cardiomyopathy and the risks early in pregnancy. It also describes the appropriate medical management, including transesophageal echocardiography and the need for collaboration of multiple medical specialists before and during delivery to provide the best possible outcome for both mother and infant. [ABSTRACT FROM AUTHOR]

Abstract: We report a series of successful awake fiberoptic intubations in patients with critical (unstable, difficult) airways using the α 2-agonist, dexmedetomidine. Dexmedetomidine has several desirable pharmacologic properties, including sedation, anxiolysis, hypnosis, analgesia, amnesia, antisialagogue effects, and a unique respiratory-sparing effect. Dexmedetomidine appears to be a useful agent for sedation during awake fiberoptic intubation in difficult airway patients. [Copyright &y& Elsevier]

The awake fiberoptic intubation (AFI) is an important part of the anesthesiologist’s armamentarium. As well as being technically challenging, it is also uncomfortable and stressful for all involved. We discuss the use of an alpha-2 agonist, dexmedetomidine, to help the clinician and patient through this procedure. The advantages of dexmedetomidine are that it produces a unique “Cooperative Sedation,” which reduces discomfort in the patient and assists in the topicalization of the airway. Most importantly, dexmedetomidine does not produce significant respiratory depression, so the airway may be secured in the safest manner possible. We discuss the history of sedation for AFI, other medications, as well as guidelines and pitfalls in the use of dexmedetomidine. [Copyright &y& Elsevier]

Fiberoptic intubation of the spontaneously breathing patient is the gold standard and technique of choice for the elective management of a difficult airway. In the hands of the properly trained and experienced user, it is also an excellent ‘plan B’ alternative when direct laryngoscopy unexpectedly fails. Fiberscope-assisted intubation through an endoscopy face mask, laryngeal mask airway or intubating laryngeal mask airway secures ventilation and oxygenation, and permits endotracheal intubation in airway emergency situations. Portable fiberscopes can be used in remote settings, increasing patient safety. This review discusses current fiberoptic intubation techniques and their applications in the management of both the anticipated and unanticipated difficult airway. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

Background: Problems with managing the airways in relation to anaesthesia causes severe morbidity and mortality. A large proportion of these adverse respiratory events is preventable. Still patients continue to die from airway disasters related to anaesthesia, also in Scandinavia. The goal of this study is to identify which efforts are likely to improve this situation.Methods: A questionnaire asking about experience, behaviour and availability of various items of equipment was mailed to all members of the Danish Society of Anaesthesiologists and were returned anonymously.Results: More than 65% of respondents have sufficient access to a flexible fibrescope, but still 17% of specialists have no access and the vast majority (>67%) has little (1-10 times) or no experience in its use for awake intubation. A total of 52-70% knew the basic principles of the ASA difficult airway algorithm, but despite this only 25-50% would perform awake intubation if a difficult intubation was expected. More than 20% of respondents had experienced preventable airway management mishaps. In all, 18-46% did not know how to oxygenate via the cricothyroid membrane.Conclusion: There is room for improvement regarding airway management skills among Danish anaesthesiologists. It is likely that airway management can be improved by: A) Better knowledge of an appropriate plan, algorithm, for airway management. B) Awake intubation used more often. C) More experience in fibreoptic intubation. D) All anaesthesiologists accepting that previous difficult intubation is an indicator of future difficulties. E) All anaesthesiologists knowing, and practising on manikins, how to oxygenate via the cricothyroid membrane. F) Always having a laryngeal mask airway immediately available when inducing anaesthesia. [ABSTRACT FROM AUTHOR]

Here, we present a case of diffi cult airway after patient consent. A young male patient presented with painless diffi cult mouth opening of 0.5 cm for 2 years, restricting him to only liquid diet. He was diagnosed as having bilateral temporomandibular joint ankylosis and was posted for release. The patient was classifi ed as diffi cult for intubation with Mallampathi IV grade; systemic examination was within normal limits. Computed tomography (CT) of the temporomandibular joint showed gross bilateral osteoarthritic changes. He was planned for awake fi beroptic nasal intubation. The patient was given a detailed explanation about the procedure. The airway was prepared with topical and nebulized lignocaine. The fi beroptic bronchoscope was mounted with a 7.0 mm cuffed armored tube and inserted through the nostrils, proceeding until the vocal cords were visualized. After confi rming with auscultation and by Capnography, patient was paralysed. Surgery was performed and the patient was extubated awake. Mouth opening improved to 2 cm. The use of the fi beroptic intubating bronchoscope in case of bilateral temporomandibular joint ankylosis with a high risk of airway control due to restricted mouth opening, a gift of modern technology, circumvents this diffi culty without compromising on patient safety, with the patient being awake too, and should be considered a safe procedure. [ABSTRACT FROM AUTHOR]

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., (© 2021. Canadian Anesthesiologists' Society.)

Background: Multiple techniques have been described for anesthetizing the lower glottis and trachea prior to awake fiberoptic intubation. The primary aim of this study is to evaluate whether direct application of local anesthetic to the lower airway via an epidural catheter under direct vision is equally efficacious when compared to use of a transtracheal block in adult patients with an anticipated difficult airway., Methods: Patients age >18 years requiring awake fiberoptic intubation who underwent upper and lower airway topicalization were observed prospectively. Following topicalization of the upper airway, patients underwent either a transtracheal block or had their trachea and lower glottis anesthetized under direct vision via dispersion of local anesthetic through a multi-orifice epidural catheter. Choice of technique was at the discretion of the attending anesthesiologist. The primary outcome was defined as the degree of coughing observed at the time of intubation based on a 4-point ordinal scale., Results: Awake intubations in 88 patients were observed with 44 patients undergoing transtracheal block and 44 patients undergoing the epidural catheter technique. Degree of coughing with intubation was similar for each approach with a coughing score of (0, IQR (0,1)) versus (0, IQR (0,1)) in the epidural catheter and transtracheal groups respectively (p = 0.385). Duration of procedure was less in the transtracheal group (1.35 ± 1.54 min) vs. epidural catheter approach (2.86 ± 2.20 min) (p< 0.001)., Conclusion: The epidural catheter and transtracheal approach appear to be equally effective at preventing coughing with intubation during awake fiberoptic intubation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, McCutchen et al.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Various drugs are used for providing favorable intubation conditions during awake fiberoptic intubation (AFOI). However, most of them have various side effects. Aim: The aim of this study was to compare the effects of dexmedetomedine and fentanyl as regards sedative effects, hemodynamic stability, intubation time and intubation attempts success during awake fiberoptic intubation. Material and Methods: A randomized double-blind prospective study was conducted on a total of 40 patients scheduled for elective cervical spine surgeries who were randomly allocated into two equal groups (n 20): (group A) patients received a bolus dose of dexmedetomidine of 1 mcg/kg over 10 min followed by a continuous infusion of dexmedetomidine at 0.5 mcg/kg/h. and fentanyl group (group B) received dose of 1 lg/kg over 10 min followed by 0.5 lg/kg/hr. Sedation score (Ramsy sedation score), hemodynamic variables, oxygen saturation, intubation time and intubation attempts were noted and compared between the two groups. Results: Ramsy Sedation Score was significantly favorable (P < 0.001) in group A in comparison to group B, moreover better hemodynamic stability during intubation (P < 0.05) and less intubation attempts were observed in group A in comparison to group B. Conclusion: The results of our study showed that dexmedetomidine provides optimum sedation without compromising airway or hemodynamic stability and with favorable intubation time and less intubation attempts during AFOI in comparison to fentanyl. [ABSTRACT FROM AUTHOR]