Manejo de vía aérea en pandemia. Caso clínico / Difficult airway during pandemia: Case report

We present a 38 years female patient with known difficult airway associated with an important anatomic deformation due to a tumoral removal back in 2014 (maxilectomy). This patient was scheduled for a new tumoral resection at the base of the skull, which was considered a potential regrowth of her maxilar sinus cancer, and because of that, the surgery admitted no delays. A multi-disciplinary approach is convenied and an AFOI with topical airway anesthesia and dexmedetomidine sedation is planned to secure the airway during surgery. The main Objective was to optimize the protective measures against SARS CoV2 transmission while securing spontaneous ventilation and patient collaboration during the procedure. To achieve this it was necessary a complex and multi-disciplinary teamwork between de intervening personal. Eventually the airway approach was successful and the surgery was carried out uneventfully. The patient was extubate and taken to the post anesthesia care unit with no recall nor sequel of the procedure.

Presentamos un caso de una paciente de 38 años con predictores de vía aérea dificultosa anticipada, asociada a importante alteración anatómica secundaria a maxilectomía, por patología tumoral, en el año 2014. Actualmente, se sometió a resección tumoral de base de cráneo, considerada una patología no diferible (tiempo sensible) en el contexto de pandemia por COVID-19. Decidimos aplicar un plan de manejo multidisciplinario e intubación orotraqueal vigil mediante fibrobroncoscopia asociada a sedación superficial con dexmedetomidina y anestesia tópica. El objetivo principal fue maximizar las medidas de seguridad, manteniendo la ventilación espontánea y colaboración de la paciente durante el procedimiento. Finalmente, resultó exitoso, siendo la paciente extubada en el quirófano pasando luego a la Unidad de Recuperación Postanestésica, sin manifestar recuerdos ni secuelas del procedimiento realizado para concluir su postoperatorio en sala común.

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

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™ 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.

“Spray-as-you-go” medical technique for awake intubation using a combination of an epidural catheter and the OptiScope in a patient with Ludwig's angina: A case report

A 73-year-old woman presented to the emergency department with submandibular pain and swelling. The patient was diagnosed to have Ludwig's angina, and she was planned to undergo urgent incision and drainage under general anesthesia. However, her physical examination revealed severe diffuse swelling extending from the bilateral submandibular spaces to the submental space and further down to the neck. As our view was blocked by the patient's neck swelling, we did not perform a regional anesthesia of the airway or a transtracheal block. Several non-invasive alternatives were considered. The “spray-as-you-go” technique was chosen, and it was performed using the OptiScope®. However, the OptiScope did not have a working channel or syringe adaptor for the administration of the local anesthetic solution. To solve this problem, we combined the OptiScope with a 27-G tunneled epidural catheter (100 cm) for the administration of lidocaine and this combination made the awake intubation successful.

Effectiveness and Safety of a Novel Approach for Management of Patients with Potential Difficult Mask Ventilation and Tracheal Intubation: A Multi-center Randomized Trial / 中华医学杂志(英文版)

<p><b>Background:</b>Patients with potential difficult mask ventilation (DV) and difficult intubation (DI) are often managed with awake intubation, which can be stressful for patients and anesthesiologists. This prospective randomized study evaluated a new approach, fast difficult airway evaluation (FDAE). We hypothesized that the FDAE approach would reduce the need for awake intubation.</p><p><b>Methods:</b>After obtaining informed consent, 302 patients with potential DV/DI undergoing elective surgeries were randomly assigned to the FDAE group (Group E) and the control group (Group C). In Group E, patients were gradually sedated, and adequacy of manual mask ventilation during spontaneous breathing was assessed at various sedation levels. Awake intubation was applied in those with inadequate mask ventilation. In Group C, DI was evaluated under local anesthesia. However, the care team could intubate under general anesthesia if the vocal cords were visible. The primary outcome was the rate of awake intubations in both groups and the induction efficiency assessed by the induction time. The secondary outcome was the incidence of serious complications.</p><p><b>Results</b>The rate of awake intubation was significantly lower in Group E than that in Group C (5.81% vs. 36.05%, χ = 42.3, P < 0.001). The induction time was much shorter in Group E than in Group C (11.85 ± 4.82 min vs. 18.71 ± 7.85 min, t = 5.39, P < 0.001). There was no significant difference in the incidence of intubation related complications between the two groups. Patients in Group E had a much lower incidence of recall (9.68% vs. 44.90%, χ = 47.68, P < 0.001) of the induction process and higher satisfaction levels than patients in Group C (t = 15.36, P < 0.001).</p><p><b>Conclusions</b>The FDAE significantly reduces the need for awake intubation and improves the efficiency of the intubation process without comprising safety in patients with potential difficult mask ventilation and DI.</p><p><b>Trial Registration:</b>No. ChiCTR-TRC-11001418; http://www.gctr.org/cn/proj/show.aspx?proj=1562.</p>

Study on the optimal dose of remifentanil combined with dexmedetomidine for awake tracheal intubation / 中国生化药物杂志

Objective To investigate the optimal dose of remifentanil combined with dexmedetomidine for awake tracheal intubation.Methods 60 cases with difficult airway general anesthesia surgery from March 2014 to August 2016 in Jinhua People's Hospital were selected and divided into group R1,R2,R3,20 cases in each group.0.6μg/kg dexmedetomidine 10 minutes micro pump intravenously,Simultaneous target-controlled infusion effect of the chamber concentration of remifentanil.2.0ng/mL remifentanil in group R1,2.3ng/mL remifentanil in group R2,2.5ng/mL remifentanil in group R3.All patients underwent full surface anesthesia with 2％lidocaine under visual soft mirror guidance.The heart rate(HR),mean arterial pressure(MAP)and Ramsay sedation score at before anesthesia(T0),at the end of the administration(T1),intubation(T2),immediately after intubation(T3),tracheal catheter placement reaction score and record tracheal intubation during respiratory depression,cardiovascular adverse events,postoperative follow-up of tracheal intubation process satisfaction.Results MAP,HR and RR at T2,T3 in group R1 were significantly higher than those in group R2 and R3,the difference was statistically significant(P<0.05).The incidence of hypertension in the group R3 was significantly lower than that in group R1,while the incidence of respiratory depression and tachycardia was significantly higher than that in group R1,the difference was statistically significant(P<0.05),RSS score and satisfaction scores in group R3 were significantly higher than those in group R1,the reaction score in group R3 was significantly lower than the group R1,the difference was statistically significant(P<0.05).Within group comparison,the mean arterial pressure and heart rate and respiratory rate at T2 and T3 in group R1 was significantly higher than those at T1,heart rate was significantly faster than T1,the respiratory rate was significantly faster than T1,the difference was statistically significant(P<0.05),T2 and T3 in group R3 were significantly slower than those at T0,the difference was statistically significant(P<0.05).Conclusion Remifentanil combined with dexmedetomidine can be safely and effectively used for awake intubation under glidescope guiding in difficult airway patients.In the full airway surface anesthesia,dexmedetomidine micropump 0.6μg/kg simultaneous target transfusion effect of the concentration of remifentanil 2.3ng/mL is a more reasonable medication.

Different target controlled concentrations of remifentanil combined with dexmedetomidine used for awake nasal intubation in cervical spine surgery patients / 临床麻醉学杂志

Objective To observe the safety and efficacy of different concentration of remifen-tanil TCI combined with dexmedetomidine for awake nasal intubation in cervical spine surgery patients and explore the clinical suitable concentrations for remifentanil TCI.Methods Sixty cervical spine surgery patients undergoing selective surgery under general anaesthesia (male 40 cases,female 20 ca-ses,aged 18-68 years,ASA Ⅰ or Ⅱ)were randomly divided into three groups according to TCI con-centration of remifentanil.The plasma concentration of remifentanil TCI of group A,B,C were 1.5 ng/ml,2.0 ng/ml,2.5 ng/ml respectively,which combined with dexmedetomidine 1 μg/kg.The value of MAP,HR,SpO2 ,RR were recorded when patients entering the operating room(T1 ), before intubation(T2 ),immediately after tracheal tube passing through nasopharynx(T3 ),immedi-ately after tracheal intubation(T4 ),immediately after tracheal tube cuff inflated(T5 )and 1min after intubation(T6 ).The success rate of first intubation were recorded.The incidence of cough,limb movement,respiratory depression,awareness and other adverse reactions during intubation were re-corded.Results In group A,MAP and HR at T3-T5 were significantly higher than those at T1 (P <0.05);SpO2 at T4-T6 and RR at T3-T6 were significantly lower than those at T1 (P <0.05)in group C.In group A,the incidence of cough and limb movements were significantly higher than those in group B,C(P <0.05).In group C,the incidence of respiratory depression was significantly higher than that in group A,B(P <0.05).Conclusion TCI concentration 2.0 ng/ml for remifentanil com-bined with dexmedetomidine can effectively inhibit the stress response to intubation with little respira-tory depression and can be widely used for awake nasal intubation in cervical spine surgery patients.

The Use of McGrath® MAC Video Laryngoscope in Difficult Airway.

Rigid indirect video laryngoscopes were designed to aid glottis visualisation in difficult airway. The McGrath® MAC video laryngoscope was designed similarly for routine use. The unique design of the blade makes it easy to use in patients with limited mouth opening and facilitates tracheal intubation without use of stylet. It is compact and easy to assemble with preparation time less than one minute making it a reasonable choice in cases of unanticipated difficult intubations. This case series demonstrates its successful use as a rescue device in patients with difficult intubation. One of the patient was intubated awake with the help of McGrath® MAC video laryngoscope thus making it an attractive alternate for fibre optic bronchoscopy assisted tracheal intubation.

Awake endotracheal intubation using a video-assisted intubating stylet in a patient with a large supraglottic mass: A case report

A 70-year-old man was scheduled for laryngeal microsurgery for supraglottic tumor. A preoperative indirect laryngoscopy demonstrated a large tumor obstructing the most of glottic opening. To prevent damage to the tumor during advancement of the endotracheal tube (ETT), an awake intubation assisted by Clarus Video System (CVS), was planned. Ten percent lidocaine spray was applied to the oropharynx. After sufficient preoxygenation, the patient was lightly sedated with continuous remifentanil and propofol infusion. The CVS, loaded with an ETT (inner diameter of 5.5 mm), was inserted orally by the anesthesiologist. The tube was carefully slid off the stylet into the glottic opening under direct vision. The anesthesiologist also confirmed that there was no damage to the tumor during 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.

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.

Comparison of anesthesia induction efficacy of dexmedetomidine with fentanyl-class drugs in patients un-dergoing awake intubation:a meta-analysis / 临床麻醉学杂志

Objective To systematically review the efficacy of dexmedetomidine and fentanyl-class drugs for induction in awake intubation patients.Methods We searched the PubMed,Embase, Cochrane library,Wanfang Database,CNKI,VIP and China Biology Medicine (CBM)for all ran-domized controlled trials (RCTs)about the efficacy of dexmedetomidine versus drugs of fentanyl class (fentanyl,sufentanil,remifentanil)for induction in awake intubation patients.The quality of the studies was evaluated by the method recommended by Cochrane Collaboration.Meta-analysis was con-ducted using the Cochrane Collaboration's RevMan 5.0 software.Results Ten RCTs involving 400 patients were included in our Meta-analysis.The results of meta-analysis showed that the ramsay se-dation scores in awake intubation patients was higher in group dexmedetomidine than that of group fentanyl-class drugs (P<0.05).Compared with group fentanyl-class drugs,the incidence of compli-cations such as hypertension,respiratory depression,bucking and post-surgical memory in the group dexmedetomidine was lower (P<0.05).Conclusion The efficacy of dexmedetomidine is better than that fentanyl-class drugs for induction in awake intubation patients.

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

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.

Clinical Study on Fiberoptic Awake Intubation and Self Pronation in Cervical Spine Disease Patients / 대한마취과학회지

In cervical spine disease patients, the authors performed awake intubation with a flexible fiberscope under local anesthetic preparation to avoid insult to the cervical spine during intubation, and had patients self pronate for positioning to prevent possible complications durings the turning from cart to operating table. We performed this method in 25patients(age15-68 years,19male female6). For oral anesthesia we used 15-20cc of 4% lidocaine in a divided dose. We injected 2 cc of 2% lidocaine for each superior laryngeal nerve block and injected 4-6 cc of 2 to 4% lidocaine through the cricothyroid membrane for transtracheal nerve block with a 22-gauge intravenous catheter. It took 5-10 minutes in 23 patients and over 10 minutes in 2 patients for local anesthetic preparation. It took less than 1 minute in 15 patients, 1-4 minutes in 6 patients and more than 4 minutes in 4 patients for fiberoptic awake intubation. We observed vocal cord movement in 6 patients and blood clot in the trachea in 7 patients. Seventeen patients did pronate without help, 5 patients needed some help and 3 patients needed full support. Among the 3 patients who needed full support, 2 patients were in a halo traction state and one was in deep sedation. Ten patients complained of pain or discomfort during intubation. This complaint may be related which the time taken for intubation and inadequate local anesthesia. There were no complications related to positioning. We concluded that fiberoptic awake intubation and self pronation for positioning is a safe and useful method for anesthetic mnagement in cervical spine disease patients.