瑞芬太尼在纤维支气管镜清醒气管插管中的应用进展

背景 困难气道患者的围术期气道管理是临床麻醉关注的热点问题.纤维支气管镜清醒气管插管(awake fibreoptic intubation,AFO1)技术是处理预见性困难气道的公认方法.然而实施AFOI的难点在于给患者提供充分镇静、镇痛的同时,又要保证患者有效的自主通气功能.瑞芬太尼作为一种较理想的麻醉性镇痛药,一定剂量下能有效抑制气管插管的应激反应,故已有用于AFOI的报道. 目的 概述及评价瑞芬太尼在AFOI中的有效性及安全性,为临床应用和进一步研究提供参考. 内容 分析瑞芬太尼用于AFOI的剂量对机体的影响、不同给药方案的优劣以及在特殊患者中的应用. 趋向 瑞芬太尼在AFOI中的应用具有诸多优势,但最佳方案仍需进一步临床研究.     

Laryngeal trauma during awake fiberoptic intubation

IMPLICATIONS: We describe three patients with difficult airways in which fiberoptic endotracheal intubation was used to insert breathing tubes into the patients' windpipes. Airway injury occurred during the use of this technique. Although largely a safe technique, care should be exercised when anesthesiologists choose equipment and when they perform this technique.     

Tracheal bleeding during awake fiberoptic intubation

Fiberoptic intubation can cause laryngeal injury during blind insertion of a tracheal tube. A patient with hypopharyngeal cancer was scheduled for laser surgery and we selected nasal fiberoptic intubation due to laryngeal deformity. Just after insertion of a tracheal tube, tracheal bleeding occurred and ventilation because difficult. Emergency tracheostomy was required to restore adequate oxygenation. A piece of mucosa and blood clot was found in the lumen of the tracheal tube and hematoma was observed on the surface of arytenoid cartilage. Careful selection and optimal manipulation of the tracheal tube is important and surgical airway access should be immediately available before fiberoptic procedure in a patient with friable and vascular-rich laryngeal lesion.     

Evaluation of remifentanil as single drug for awake fiberoptic intubation

BACKGROUND: Awake fiberoptic intubation is the standard of care for difficult airway management. Quality and success of this technique depend on the experience of the intubating physician and the proper preparation of the patient. The aim of this study was to compare remifentanil (R) as single agent to the combination of fentanyl (F) and midazolam (M), which have been the drugs for analgesia and sedation for this procedure. METHODS: Seventy-four adult patients requiring nasotracheal intubation were randomly assigned to one of two groups. In group I, (n=37) R was administered in incremental dosages (0.1-0.25-0.5 microg/kg/min) by an infusion pump according to comfort, level of sedation and respiratory depression. In group II, (n=37) analgesia and sedation was achieved by F 1.5 microg/kg and doses of between 1 and 10 mg M, titrated to the individual needs. Patient reactions like grimacing, movement and coughing during intubation were assessed, as well as patient recall of the procedure. Haemodynamic and respiratory parameters were continuously recorded. RESULTS: Group I patients better tolerated nasal tube passage (P<0.001) and laryngeal tube advancement (P<0.001) than group II. Remifentanil better suppressed hemodynamic response to nasal intubation (P<0.001). No significant difference in respiratory data was recorded. In group I more recall of the procedure was observed (six vs. zero patients, P<0.05). CONCLUSION: Remifentanil in high doses, as the single agent for patient preparation for awake fiberoptic intubation seems to improve intubating conditions, quality and reliability of the procedure. However, a higher incidence of recall is to be expected.     

Dexmedetomidine for conscious sedation in difficult awake fiberoptic intubation cases

Currently used methods of sedation for fiberoptic intubation such as benzodiazepines, propofol, or opioids have their limitations. Dexmedetomidine (DEX) is a selective alpha-2 adrenergic agonist that has been used clinically for its sympatholytic, analgesic, and sedative properties. We report on 4 patients with particularly difficult airways who underwent successful awake fiberoptic intubation with DEX. Dexmedetomidine was used to provide a moderate level of conscious sedation without causing respiratory distress or hemodynamic instability during fiberoptic intubation.     

Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation

BACKGROUND: Advancing the endotracheal tube (ETT) over a flexible bronchoscope (FB) during awake fiberoptic orotracheal intubation is often impeded. The goal of this study was to identify the sites and mechanisms that inhibit the passing of the ETT into the trachea. METHODS: Forty-five consenting patients underwent a clinically indicated awake fiberoptic orotracheal intubation. After topical anesthesia, nerve block, or both, an awake fiberoptic orotracheal intubation was performed. The placement of the FB and advancement of the ETT over the FB were videotaped using a second nasally inserted FB. An otolaryngologist later reviewed the videotaped data. RESULTS: The right arytenoid or the interarytenoid soft tissues inhibited advancement of the ETT in 42 and 11% of all patients, respectively. In all cases in which the FB was located on the right side of the larynx, failure of ETT advancement almost always occurred at the right arytenoid. Withdrawing the ETT and rotating it 90 degrees counterclockwise resulted in successful intubation on the second, third, and fourth attempts in 26.6, 20, and 0.7% of patients, respectively. CONCLUSION: The right arytenoid frequently inhibits advancement of the ETT over the FB into the trachea during awake fiberoptic orotracheal intubation. The FB position in the larynx before tube advancement and the orientation of the ETT are relevant factors in failure of advancement of the ETT into the trachea. The authors recommend positioning the FB in the center of the larynx and orienting the bevel of the ETT to face posteriorly during the first attempt at intubation.     

Arterial oxygen desaturation during awake endotracheal intubation.

Five patients requiring general anesthesia but presenting with compromised airways were successfully intubated by blind awake intubation with the aid of regional anesthesia and the use of appropriate sedation. Arterial blood gases were collected at three intervals: presedation, postsedation, and postintubation. Analysis of the blood gases revealed varying degrees of hypoxemia, hypercarbia, and acidosis following deep sedation before intubation. A decrease in oxygen saturation was also observed. Supplemental oxygen is suggested to avoid the effects of arterial desaturation during the sedation process. If oxygen is not administered, the risk of moderate hypoxia associated with blind awake intubation must be considered along with alternative problems including loss of protective reflexes or the inability to ventilate during induction and intubation via a direct technique.     

Emergency endotracheal intubation under fiberoptic endoscopic guidance for malignant laryngeal obstruction

Endotracheal intubation under fiberoptic flexible scope guidance is an easy technique to master and can be performed under local anesthesia. It provides immediate and safe intubation of malignant obstructive lesions of the larynx and allows surgical resection and reconstruction to be carried out as an emergency procedure. Ten patients with malignant obstructive lesion of the larynx were intubated and managed successfully in this manner. Refinements of intubation techniques under fiberoptic endoscopic guidance were described.     

Attenuating the hypertensive response to laryngoscopy and endotracheal intubation using awake fibreoptic intubation

Blood pressure and pulse rate measurements were recorded in 35 patients undergoing endotracheal intubation during general anaesthesia (Group A), and 35 patients who had an awake fibreoptic intubation under local anaesthesia (Group B). The mean arterial pressure in Group A rose by a mean of 35 mmHg immediately after intubation, compared with a mean fall of 9 mmHg in Group B. The mean pulse rate in Group A rose by 24 beats per minute (b.p.m.) immediately after intubation, compared with a rise of 3 b.p.m. in Group B. Both these differences were statistically significant (P less than 0.0001 and P less than 0.001 respectively, Mann Whitney U test). Postoperative discomfort was assessed 24 h later by means of linear analogue scales. There was a statistically higher mean score in relation to nose discomfort in Group B (P less than 0.002). Awake fibreoptic intubation successfully reduces the pressor response to endotracheal intubation in normotensive adults. It is suitable for use in those patients who are at risk from the pressor response.     

The use of AIR-Q as conduit for fiberoptic endotracheal intubation in adult paralyzed patients

BackgroundThe AIR-Q Laryngeal Mask (Cookgas LLC; distributed by Mercury Medical) is a supraglottic device present in the market since 2004. It has different sizes for pediatric and adult use. This device proved to be of utmost importance in the management of difficult airway [1]. The study evaluates the different adult sizes of the Air Q when used for intubation regarding the ease of insertion, the laryngeal view grade, their efficacy as conduit for standard cuffed endotracheal tubes using fiberoptic bronchoscope. The study also records the time of intubation, the ease and time of removal of the AIRQ over a removal stylet without dislodgement of the tube from trachea. Any complications related to the use of AIRQ were also recorded such as laryngeal oedema, blood streaked mucous, trauma to the airway, laryngeal spasm or aspiration.MethodsSixty adult patients aged 20–50 years, ASA I, II undergoing elective surgeries requiring general anesthesia, were enrolled in the study. The patients were divided into 2 equal groups according to their body weight. The body weight of the first group ranged from 50 to 70 kg and used the Air Q 3.5 for intubation with an endotracheal tube (ETT) 7 mm ID, while the body weight of the second group ranges from 70 to 100 kg and used the Air Q 4.5 for intubation with a tube 7.5 mm ID. The number of attempts of insertion, the seal pressure, the laryngeal view grade, the time and the number of attempts of intubation, time of removal of the AIRQ over the tube without dislodgement, and any complications related to the use of AIRQ were recorded such as laryngeal oedema, blood streaked mucous, trauma to the airway, laryngeal spasm or aspiration.ResultsThe insertion and removal of the AIRQ were easy and successful in all patients of both groups. The endotracheal intubation by fiberoptic bronchoscope through the Air Q was successful and easy in both groups. Grade 5 laryngeal view was seen with AIRQ 4.5 in some patients with higher body weight.ConclusionThe insertion of AIRQ in adult patients is easy and provides an effective conduit for the standard cuffed endotracheal tubes using fiberoptic bronchoscope. The removal of the AIRQ over the removal stylet is easy without dislodgement of the tube. Because of higher incidence of down folding of the epiglottis in some obese patients, they are better intubated under direct vision with the use of fiberoptic bronchoscope.