A Review of Intubation Techniques in Anaesthetic Management of Temporomandibular Joint Ankylosis

Intubation of a patient with temporomandibular joint ankylosis is a challenge for every anaesthesiologist. Dependable anaesthetic technique is most desired by all anaesthesiologists. The purpose of the present article is to have a brief overview of temporomandibular joint ankylosis, its clinical features, management and to review literature demonstrating various intubation techniques available to an anaesthesiologist while managing patients with temporomandibular joint ankylosis.

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.

Evalution of the combination of dexmedetomidine and fentanyl in sedation during awake nasotracheal intu-bation / 实用医学杂志

Objective To evalute the combination of dexmedetomidine and fentanyl in sedation during awake nasotracheal fiberoptic intubation. Methods One hundred and twenty ASAⅠ or Ⅱ patients scheduled to receive general anesthesia were randomly divided into 3 groups (n = 40 in each group). Patients in group L received an infusion of 1 μg/kg dexmedetomidine,patients in group H received an infusion of 2 μg/kg dexmedeto-midine ,and patients in group DF received an infusion of 1 μ g/kg dexmedetomidine added to 1 μ g/kg fentanyl. Nasotracheal intubation was performed after complete topical anesthesia. HR and MAP were recorded before anes-thesia(baseline,T0),before intubation(T1)and immediately after intubation(T2),respectively. The intubation score(vocal cord movement,coughing and limb movement),fiberoptic intubation score,nasotracheal intubation score and airway obstraction score were assessed in all aptients. On the first post-operative day,recall,adverse events and satisfaction score were also assessed. Results HR and MAP at T1 in three groups were significantly lower than those at T0(P < 0.05,respectively ). HR and MAP at T2 in group L were significantly higher than those in group H and DF(P<0.05,respectively). More incidence of vocal cord closed,severe cough,severe limb movement,heavy grimacing,defensive movement of head and hands after nasotracheal intubation were observed in group L than those in the other two groups. The incidence of airway obstraction and bradycardia in group H were higher than those in group L and DF. Patients in group L had lower postoperative satisfaction scores. Conclusion Adding 1 μg/kg fentanyl to 1 μg/kg dexmedetomidine is a good method for awake nasotracheal fiberoptic intuba-tion,which can prevent the risk of airway obstruction associated with the increase of dexmedetomidine dose,with the achievement of the same favorable sedation.

Efficacy of ultrasound-guided superior laryngeal nerve block for awake orotracheal fiberoptic intubation / 临床麻醉学杂志

Objective To observe the efficacy of the ultrasound-guided superior laryngeal nerve block for awake orotracheal fiberoptic intubation.Methods Forty patients with limited cervical activity scheduled for elective surgery under general anesthesia,23 males and 17 females,aged 18-65 years,ASA physical status Ⅰ or Ⅱ were chosen.According to random number table method,they were randomly divided into two groups (n =20).Group N received superior laryngeal nerve block u-sing the acupoint-located method by anatomical landmark,and group D was under ultrasound-guided, combined with airway anesthesia.Awake orotracheal fiberoptic intubation was then performed.Intu-bation time and the changes of MAP,HR,Ramsay sedation score were recorded at the time of bur-glary (T0 ),before the endotracheal tube into the mouth (T1 ),endotracheal tube into the glottis im-mediately (T2 ),5 min after intubation (T3 ).Ramsay score was rated to assess the patients'comfort and tolerance,complications during intubation process were documented,the patient's satisfaction was received.Results Compared with the group N,the intubation time of group D was significantly shorter [(0.5±0.1)min vs (1.0±0.2)min,P <0.05].In group N,MAP and HR were obviously higher during intubation with lower Ramsay sedation score at T2 compared with group D (P <0.05). Patients in group D had lower comfort score and tolerance grade during intubation (P <0.05).The incidence of nausea,vomiting,restlessness and pharyngalgia were significantly lower in group D (P< 0.05 ).Besides, patients during intubation in group D were more satisfactory (P < 0.05 ). Conclusion Ultrasound-guided superior laryngeal nerve block for awake orotracheal fiberoptic intuba-tion could provide an ideal sedative effect,maintain stable circulation and keep patients tolerable.

A randomised comparative study of dexmedetomidine and midazolam for sedation during awake fiberoptic intubation in laproscopic cholecystectomy patients.

Fiberoptic nasotracheal intubation is an effective method for the management of patients with difficult airways. An ideal sedation regimen would ensure patient’s comfort, attenuation of airway reflexes, patient’s co-ordination, haemodynamic stability and amnesia. It is critical for both the surgeon and the anesthesiologist to understand the physiologic consequences of laparoscopy and to work in cooperation to achieve a good surgical outcome. Methods: Patients were randomly allocated to midazolam (MDZ) group (group 1) and dexmedetomidine (DEX) group (group 2). DEX patients received dexmedetomidine 1μg/kg, followed by an infusion of dexmedetomidine 0.1μg/kg/hr titrated to 0.7μg/kg/hr to achieve RSS ≥2. MDZ subjects received IV midazolam 0.05mg/kg with additional doses given to achieve a RSS ≥ 2. Measurements: Pulse rate, systolic and diastolic blood pressures and SpO2 recorded during pre-oxygenation, one minute prior to introduction of fiberscope and then every minute for the following five minutes and beginning one minute before endotracheal intubation and then every minute until the endotracheal tube was secured, patient’s tolerance assessed on 5 point fiberoptic intubation score during fiberscopy and endotracheal intubation, total comfort score values assessed during pre-oxygenation, fiberscopy and endotracheal intubation and patient’s response to 24 hour post op questionnaire assessment were measured. Results: DEX group patients were significantly more quiet and more harmonius during awake fiberoptic intubation (AFOI) than were the MDZ group patients. The DEX group patients were found to have a lower mean Heart Rate than the MDZ patients. Conclusions: Both dexmedetomidine and midazolam are effective for fibreoptic intubation. Dexmedetomidine allows better endurance, stable haemodynamic status and a patent airway.

Intubación endotraqueal con broncoscopio fibróptico flexible en paciente con bocio no tóxico severo / Endotracheal intubation with flexible fiberoptic bronchoscope in patients with severe nontoxic goiter

Introducción: Los pacientes con bocio severo no tóxico pueden manifestar síntomas obstructivos de la vía aérea con implicaciones importantes para la conducta anestesiológica. El uso del broncoscopio flexible es la alternativa de primera línea para la intubación endotraqueal de estos enfermos. Paciente: Mujer de 34 años con bocio severo que ingresó para exéresis quirúrgica de un nódulo frío en el polo inferior del lóbulo derecho del tiroides. Se intubó la tráquea con el uso de un broncoscopio flexible mientras se mantuvo respirando espontáneamente, sedada con una infusión continua de dexmedetomidina. Conclusiones: La intubación fibróptica se considera el «patrón de oro¼ para el abordaje de la vía aérea difícil anticipada. El estudio y la práctica de esta técnica por el anestesiólogo resultan una necesidad perentoria.

Background: Patients with severe nontoxic goiter can present obstructive symptoms of the airways with important implications for the anaesthesiology behaviour. The use of the flexible fiberoptic bronchoscope is a first line alternative for the endotracheal intubation in these patients. Patient: 34-year-old woman suffering from severe goiter who was atmitted to hospital to undergo a surgical exerecis of a cold nodule located in the lower pole of the right lobe of the thyroid gland. The trachea was intubated using a flexible bronchoscope while she was breathing spontaneously and sedated with a continuous infusion of Dexmedetomidine. Conclusions: The fiberoptic intubation is considered "the gold pattern" for the approach of the anticipated difficult airway. The study and practice of this technique by the anaesthesiologist constitute an urgent need.

Usefulness of a Cook(R) airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation in a neonate with Pierre Robin syndrome: A case report / 대한마취과학회지

The case of a 33-day-old boy with Pierre Robin syndrome using a Cook(R) airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation is presented. After induction with sevoflurane, classical reusable laryngeal mask airway (LMA) #1 was inserted and ultrathin fiberoptic bronchoscope (FOB) was passed through. A Cook(R) airway exchange catheter (1.6 mm ID, 2.7 mm OD) was passed through the LMA under the guidance of the FOB but failed to enter the trachea despite many trials. Then, an endotracheal tube (3.0 mm ID) was mounted on the FOB and railroaded over the FOB. After successful intubation, the Cook(R) airway exchange catheter was placed in the midtrachea through the lumen of the endotracheal tube. Even though the tracheal tube was accidentally displaced out of the trachea during LMA removal, the endotracheal tube could be easily railroaded over the airway exchange catheter.

Anesthetic management for a patient with severe mento-sternal contracture: difficult airway and scarce venous access: A case report / 대한마취과학회지

There are many problems in the anesthetic management of patients with scar contracture. In this case, a 41-year-old male with severe scar contracture on his face, neck, anterior chest, and both shoulders underwent surgery for resurfacing with flaps. We tried to awake fiberoptic orotracheal intubation with GlideScope(R) Video laryngoscope guide after surgical release of contracture under local anesthesia. We report a successful management of a patient with severe burn contracture achieved by combined effort of surgeons and anesthesiologists.

Anesthesia for massive retrosternal goiter with severe intrathoracic tracheal narrowing: the challenges imposed: A case report / 대한마취과학회지

Anesthetic management of patients with mediastinal masses remains challenging as acute cardiorespiratory decompensation may follow induction of anesthesia. We describe a 57 year old lady with massive retrosternal goiter and severe intrathoracic tracheal compression who had a total thyroidectomy. Comprehensive contingency plans were an essential prerequisite for successful management of difficult airway, including multidisciplinary involvement of otorhinolaryngologic and cardiothoracic surgeons preparing for rigid bronchoscopy and cardiopulmonary bypass. Awake oral fiberoptic intubation was performed under dexmedetomidine sedation. Severe tracheal narrowing necessitated usage of a 5.0 mm uncuffed flexometallic endotracheal tube. Anesthesia was maintained with sevoflurane and dexmedetomidine infusion with target controlled infusion of remifentanil as analgesia. No muscle relaxant was given. Surgical manipulation led to intermittent total tracheal compression and inadequate ventilation. The tumor was successfully removed via the cervical approach. A close working relationship between anesthesiologists and surgeons was the key to the safe use of anesthesia and uneventful recovery of this patient.

Fiberoptic intubation through a laryngeal mask airway as a management of difficult airwary due to the fusion of the entire cervical spine: A report of two cases / 대한마취과학회지

Patients with cervical spine instability and limited range of motion are challenge to anesthesiologists. It is important to consider alternatetive methods for securing the airway while maintaining neutral position and minimizing neck motion, because these patients are at increased risk for tracheal intubation failure and neurologic injury during airway management or position change. We experienced two cases that patients had cervical spine instability and severe limited range of motion due to the fusion of the entire cervical spine. One patient was a 6-year-old girl weighing 12.7 kg and had Klippel-Feil syndrome with Arnold-Chiari malformation, the other was a 24-year-old female weighing 31 kg and had juvenile rheumatoid arthritis. We successfully performed the intubation by using the fiberoptic intubation though a laryngeal mask airway in these two cases.

Laryngoscope-Assisted Fiberoptic Intubation in General Anesthesia : A report of 2 cases / 대한마취과학회지

Fiberoptic intubation is an important method of tracheal intubation, especially in patients with difficult airway. As fiberoptic bronchoscopy relies on clear airspace ahead of the fiberscope tip, increasing airway obstruction may cause increasing difficulty. A clear airway that allows the passage of the fiberscope is usually present in awake patients, whereas in anesthetized patients the airspace in the oropharynx is reduced; the soft palate, base of tongue and epiglottis may be applied to the posterior pharyngeal wall due to the reduction in muscle tone. Hence, fiberoptic intubation may be difficult in anesthetized patients, and maneuvers to open the airway may be required. We report a simple and useful two-person intubation technique that uses the fiberoptic bronchoscope and conventional laryngoscope, which facilitated tracheal intubation in patients who had unanticipated difficult intubation.

Fiberoptic Bronchoscopic Intubation in a Patient with Treacher-Collins Syndrome / 대한마취과학회지

The Treacher-Collins syndrome is a rare congenital anomaly characterized by mandibular, maxillary, and malar bone hypoplasia, bilateral deformities of auricles, lower lid defects, and antimongoloid slant of the palpebral fissures. The syndrome is associated with considerable difficulty in airway management during anesthesia; difficult, often impossible, endotracheal intubation and face mask ventilation. We report case of Treacher-Collins syndrome in 13-year-old girl who was intubated with fiberoptic bronchoscope and discuss anesthetic consideration.

Fiberoptic Nasotracheal Intubation in Pediatric Patients with Difficult Mouth Opening: A case report / 대한마취과학회지

We present two pediatric patients, one with Pierre Robin syndrome and one with temporomandibular joint ankylosis with limited mouth opening. They had historical and physical evidence of airway obstruction, difficult feeding, and sleep disturbance. They were scheduled for oromaxillofacial surgery. In each case, two different-sized fiberoptic bronchoscopes were used for nasotracheal intubation. After loss of consciousness following an IV injection of ketamine or inhalation of sevoflurane while maintaining spontaneous respiration, 10% lidocaine was sprayed into one nostril. Following insertion of a 60 cm Olympus LF-2 fiberoptic bronchoscope (OD: 3.8 mm) through the same nostril without tube placement, the vocal cords were visualized and topical anesthesia of the larynx was achieved by spraying 2% lidocaine through the biopsy channel. Thirty seconds later, the bronchoscope was passed into the trachea and 2% lidocaine was sprayed intratracheally. Then, the bronchoscope was withdrawn. An endotracheal tube was advanced through the same nostril and positioned in the nasopharynx and the ultrathin fiberoptic bronchoscope (OD: 2.2 mm) was threaded through the tube. There was neither a cough nor laryngeal spasm during advancement of the tube into the trachea. Extubation was performed without compromise in the operating room. The patients were discharged uneventfully.

The Two Step Fiberoptic Approach in the Management of a Difficult Pediatric Airway due to a Vallecular Cyst / 대한마취과학회지

A 6-yr-old male weighing 20 kg with the diagnosis of a large vallecular cyst in the oropharynx was scheduled for surgical excision. After a slight loss of consciousness following an IV injection of ketamine 10 mg while maintaining spontaneous respiration, 4% lidocaine was sprayed into the right nostril. An uncuffed 4 mm OD wire-reinforced endotracheal tube was advanced through the right nostril and positioned in the nasopharynx. An ultrathin 60 cm Olympus LF-P fiberoptic bronchoscope (OD: 2.2 mm) was threaded and the vocal cords and surrounding structures were identified as intact. The endotracheal tube and fiberscope were withdrawn. Ketamine 10 mg was injected intravenously again. Following direct insertion of an Olympus fiberoptic bronchoscope (OD: 3.8 mm) through the right nostril without tube placement and visualization of the vocal cords, topical anesthesia of the larynx was achieved by spraying 1 ml 2% lidocaine through the biopsy channel. Thirty seconds later, it was passed into the trachea and 1 ml 2% lidocaine was sprayed intratracheally. The bronchoscope was withdrawn. The 4 mm uncuffed wire-reinforced tube was passed again through the right nostril and an ultrathin fiberoptic bronchoscope (OD: 2.2 mm) was threaded over the tube, and passed smoothly without resistance. There was neither laryngeal spasm nor cough. Anesthesia was maintained with enflurane 2.0 vol%, N2O (1.5 L/min) and O2 (1.5 L/min). The mass was successfully excised and extubated without compromise. The patient was uneventfully discharged the next day.

How Many Attempts are Needed for Learning Fiberoptic Orotracheal Intubation? / 대한마취과학회지

BACKGROUND: The value of the fiberoptic laryngoscope in difficult tracheal intubation is well established. In recent years there has been a significant interest in and increase in learning this valuable skill by anesthesiologists. This study assesses the minimum number of attempts needed for proficiency in fiberoptic orotracheal intubation. METHODS: Eight anesthesia residents with experience in rigid larygoscopic intubation, but who were beginners in fiberoptic intubation, participated in this study. In a randomized fashion, each resident performed 50 fiberoptic orotracheal intubations. All intubations were performed under general anesthesia and muscle paralysis. Success rate and intubation time of fiberoptic orotracheal intubation and SpO2 were recorded. We have compared success rate with intubation time of fiberoptic orotracheal intubation and grade of laryngoscopic view. RESULTS: The mean success rate of fiberoptic orotracheal intubation was 75% in the first 10 intubations. Thereafter the success rates were higher than 90%. The mean time to achieve successful orotracheal fiberoptic intubation were significantly decreased to 30 attempts. There was no correlation of laryngoscopic grade with intubation time and success rate. No hypoxia occurred in any patient. CONCLUSIONS: We concluded that an acceptable level of technical expertise in fiberoptic orotracheal intubation is achieved after 30 intubation attempts.

A Endotracheal Intubation in a Child with Mocopolysaccharidoses Using the Fiberoptic Laryngoscopy / 대한마취과학회지

Mucopolysaccharidoses are a group of inherited disorders of metabolism resulting in the deposition of mucopolysaccharide in various tissues. This leads to organ dysfunction and anatomical abnormalities which can be important to the anesthetist. These abnormalities result in airway difficulty and difficult intubation. We successfully performed endotracheal intubation in a case of mucopolysaccharidoses in a 9-year-old female patient using fiberoptic laryngoscopy.

Nasotracheal Intubation Using Fiberoptic Bronchoscope and Guidewire in a Pediatric Mandibular Fracture Patient: A case report / 대한마취과학회지

Although the endotracheal intubation using laryngoscope can usually be performed under general anesthesia, it may be very difficult in situations such as head and neck trauma, hemorrage, or deformity. Recently we performed antegrade fiberoptic nasotracheal intubation with a guide wire. A 15-month aged female child with mandibular fracture was scheduled for open reduction and internal fixation under general anesthesia. She was anticipated difficult intubation due to displacement of the fracture site. After induction of anesthesia, we passed an adult fiberoptic bronchoscope (O.D. 3.8 mm, LF-2, Olympus optical co, Japan) to vocal cord via right nostril. Then a guidewire was inserted through the suction port of bronchoscope, and bronchoscope was removed in a state of guidewire in situ. We slid the endotracheal tube over guidewire according to Seldinger's technique. We think that nasotracheal intubation using an adult fiberoptic bronchoscope and a guidewire is good for children under 2 years old who are expected the difficult intubation.

The Clinical Assessment of the Efficacy and Safety of the Intubating Laryngeal Mask Airway / 대한마취과학회지

BACKGROUND: The intubating laryngeal mask airway (ILMA) was introduced recently as an effective ventilatory device and intubation guide. The following study was designed to assess not only efficacy but also safety of the ILMA. METHODS: Sixty adult patients who were randomly assigned in 3 groups (Group 1, 2, 3), ASA class 1 or 2, undergoing elective surgery were induced with intravenous injection of fentanyl, thiopental sodium, vecuronium, lidocaine and inhalation of O2, N2O, enflurane. In Group 1 (n=20), the patients were intubated with Macintosh curved blade and endotracheal tube. In Group 2 (n=20), blind tracheal intubation using an ILMA was attempted. In Group 3 (n=20), we applicated the ILMA to a fiberoptic bronchoscope-aided tracheal intubation. Then we decided success rates for blind and fiberoptic-guided passage of an endotracheal tube via the ILMA. We measured systolic, diastolic arterial pressure and heart rate before administration of induction agent, 1 and 5 minutes after induction, just after intubation, 1, 2, 3 and 5 minutes after endotracheal intubation. RESULTS: The success rates for blind (Group 2) and fiberoptic-guided (Group 3) passage of an endotracheal tube via the ILMA were 70% and 100% respectively. There were no statistically significance in the systolic, diastolic arterial pressure and heart rate when compared to value of any other groups at any time but higher in all groups when compared to preinduction value of each group just after intubation. CONCLUSIONS: Though the ILMA may be an effective intubation guide, it doesn't blunt hemodynamic changes effectively than standard laryngoscopic intubation.

Atelectasis Due to Epistaxis Aspiration during Awake Fiberoptic Nasotracheal Intubation / 대한구급학회지

Indication for fiberoptic intubation in an awake patient include almost any abnormality that may hinder the expeditious placement of an endotracheal tube during anesthetic induction. An epistaxis is the most frequent complication of nasotracheal intubation. The patient was admitted for open reduction and internal fixation due to severe mandible fracture. We experienced a case of atelectasis due to epistaxis aspiration during awake fiberoptic nasotracheal intubation in the conscious patient regionally anesthetized by both superior laryngeal nerve block and translaryngeal anesthesia, which is treated by saline irrigation, suction, active coughing and chest percussion.

Sedation and Hemodynamic Stability during Fiberoptic Awake Nasotracheal Intubation: Comparison between Propofol Infusion and Intravenous Boluses of Fentanyl and Midazolam / 대한마취과학회지

BACKGROUND: Crucial to the success of fiberoptic awake tracheal intubation is proper preparation of the patient; this technique will work well in most patients when they are quiet and cooperative and have a larynx nonreactive to physical stimuli. We have attempted to ascertain how well these conditions are achieved with a low-dose infusion of propofol, because of its pharmacological profile. METHODS: Thirty patients, physical status by American Society of Anesthesiologists (A. S. A.) I-II, scheduled for oral and maxillofacial surgery, were randomly assigned to receive either propofol infusion 1 mg kg-1 h-1 preceded by a 1 mg kg-1 bolus (Group P) or intravenous fentanyl 1ug kg-1 and midazolam 0.05 mg kg-1 (Group F). These two groups were compared in terms of hemodynamic profile, sedation score, condition for intubation, coughing and swallowing. RESULTS: There were no statistically significant differences in mean arterial blood pressures according to time between two groups. But in Group F, heart rates were significantly increased in immediately after transtracheal injection of lidocaine, immediately before the fiberoscopy was started, 1, 2 minutes after start of fiberoscopy, compared to Group P (p<0.05). The patients in Group P were more sedated than those in Group F (p<0.05) but there were no significant differences in condition for intubation, reflex of coughing and swallowing, duration of fiberoptic intubation. CONCLUSIONS: We conclude that propofol is useful sedative agent in fiberoptic awake intubation with similar efficacy to midazolam and fentanyl but with more profound sedation and stable hemodynamic profile. These represent significant advantages for severe anxious or hypertensive patients and prolonged procedure of intubation.