Awake fibreoptic intubation skills in obstetric patients: a survey of anaesthetists in the Oxford region

A survey of anaesthetists in the Oxford region was conducted to determine their skills and practice in performing awake fibreoptic intubation. Forty-two consultant obstetric anaesthetists (group O), 21 consultant anaesthetists with an interest in difficult airway management (group D) and 20 anaesthetic specialist registrars in their final training year (group S) were sent a questionnaire on management of a patient with a known difficult airway for elective caesarean section. All but one responded. If regional anaesthesia was unsuccessful or contraindicated, 75/82 respondents (91.5%) would choose to secure the airway by awake intubation. Of the remaining seven, six would use general anaesthesia and spontaneous respiration, five (6.1%) with the laryngeal mask airway and one (1.2%) with mask and airway and one (1.2%) local infiltration by the surgeon. Although awake fibreoptic intubation was the technique chosen by 98.7%, only six (8.1%) had experience of its performance in an obstetric patient. Of the 68 anaesthetists without such experience, only 12/31 (38.7%) group O compared to 13/18 (72.2%) group D and 12/19 (63.2%) group S would be confident to perform awake fibreoptic intubation in an obstetric patient. Only one anaesthetist in the survey practised awake fibreoptic intubation in non-obstetric patients regularly (>3/month). However, 69/82 respondents replied that all consultant obstetric anaesthetists should be experienced in performing awake fibreoptic intubation. We conclude that despite the value of awake fibreoptic intubation, consultant obstetric anaesthetists are less confident in performing it than those with an interest in difficult airway management and final year specialist registrars.     

Fibre-optic awake intubation for caesarean section in a parturient with predicted difficult airway

Anaesthetic management of a parturient with predicted difficult airway presenting for caesarean section (CS) is not a straightforward decision: general anaesthesia should be avoided because intubation can be impossible and a "cannot intubate, cannot ventilate" scenario might ensue, on the other hand regional techniques can be unsuccessful or, though rarely, have complications that require emergency intubation. The case is presented of a primigravida admitted to hospital at 37 weeks' gestation with hypertension, intrauterine growth retardation and oligohydramnios. After a few days' observation, it was decided to proceed with an elective CS. The preoperative airway examination revealed a poor mouth opening with an interdental distance of 20 mm and a Mallampati class IV. The patient was classified as a case of difficult intubation and the following anaesthetic options were considered: epidural anaesthesia, spinal anaesthesia and awake fibreoptic intubation followed by general anaesthesia. The pros and the cons of these techniques were explained to the patient and it was suggested that awake fibreoptic intubation was the safest option. The patient gave her consent, so an uneventful nasal awake fibreoptic intubation was carried out under local anaesthesia. This case report offers the opportunity to underline the risk to perform a central blockade in a parturient with predicted difficult intubation, arguing that the safest course of action is an awake fibrescopic intubation, besides some controversial points to safely perform awake fibreoptic intubation in obstetric patients are discussed.     

Incidence,causes, and management of failed awake fibreoptic intubation—A retrospective study of 833 procedures

Awake fibreoptic intubation has been considered a gold standard in the management of the difficult airway. However, failure may cause critical situations. The aim of this study was to investigate the incidence and causes of failed awake fibreoptic intubation at a tertiary care hospital. The study was conducted at St. Olav University Hospital in Trondheim, Norway. Problems occurring during anaesthesia are routinely recorded in the electronic anaesthesia information system (Picis Clinical Solutions Inc.), including difficult intubations. We applied text search on all anaesthesia records between 2011 and 2021 and identified 833 awake fibreoptic intubations. The anaesthesia records were examined to identify failed awake fibreoptic intubations, the cause of failure and how the airway ultimately was secured. Among 233,938 patients who received anaesthesia, 90,397 received tracheal intubation and 833 received awake fibreoptic intubation. Twenty-nine of the procedures failed. In nine patients the failure caused loss of airway control with desaturation and hypoventilation. The major causes of failure were dislodged tube after induction of general anaesthesia (n = 8), patient distress (n = 5), tube not able to pass (n = 5), and airway bleeding (n = 3). The situations were primarily solved using direct laryngoscopy, with or without bougie, or with video laryngoscopy. Tracheostomy was performed in four patients. Awake fibreoptic intubation failed in 3.5% of patients, most often due to dislocation, problems passing the tracheal tube, or patient discomfort. The failure rate was higher than in previous studies.     

Fibreoptic intubation

Although not widely utilized, fibreoptic techniques represent a dramatic advance in the management of the difficult intubation. Particularly suited to the awake patient in the elective setting, fibreoptic intubation can abo be useful in selected emergency situations, and can be done under general anaesthesia. In the awake patient fibreoptic intubation maintains a wide margin of safety while producing minimal patient discomfort, but requires adequate local anaesthesia of the airway. Intimate familiarity with the bronchoscope and the anatomy of the upper airway is essential as is careful attention to various aspects of technique. Intubation mannequins can be readily utilized to develop dexterity in bronchoscopic manipulation and intubation workshops are also effective in improving skills. This CME article provides the clinician with a detailed approach to the technique of fibreoptic intubation based on the author’s personal experience supplemented by a limited literature review. Fibreoptic intubation is not a difficult skill to master and should be in the armamentarium of all practising anaesthetists.     

A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre

Contemporary data are lacking for procedural practice, training provision and outcomes for awake fibreoptic intubation in the UK. We performed a prospective cohort study of awake fibreoptic intubations at a tertiary centre to assess current practice. Data from 600 elective or emergency awake fibreoptic intubations were collected to include information on patient and operator demographics, technical performance and complications. This comprised 1.71% of patients presenting for surgery requiring a general anaesthetic, with the majority occurring in patients presenting for head and neck surgery. The most common indication was reduced mouth opening (26.8%), followed by previous airway surgery or head and neck radiotherapy (22.5% each). Only five awake fibreoptic intubations were performed with no sedation, but the most common sedative technique was combined target‐controlled infusions of remifentanil and propofol. Oxygenation was achieved with high‐flow, heated and humidified oxygen via nasal cannula in 49.0% of patients. Most operators had performed awake fibreoptic intubation more than 20 times previously, but trainees were the primary operator in 78.6% of awake fibreoptic intubations, of which 86.8% were directly supervised by a consultant. The failure rate was 1.0%, and 11.0% of awake fibreoptic intubations were complicated, most commonly by multiple attempts (4.2%), over‐sedation (2.2%) or desaturation (1.5%). The only significant association with complications was the number of previous awake fibreoptic intubations performed, with fewer complications occurring in the hands of operators with more awake fibreoptic intubation experience. Our data demonstrate that awake fibreoptic intubation is a safe procedure with a high success rate. Institutional awake fibreoptic intubation training can both develop and maintain trainee competence in performing awake fibreoptic intubation, with a similar incidence of complications and success compared with consultants.     

Perioperative use of the modified nasal trumpet in 346 patients

Background. The modified nasal trumpet (MNT) is a prepackagednasopharyngeal airway modified with distal holes and fittedwith a 15 mm adaptor allowing connection to an anaesthesia circuit.It may be useful for airway management during anaesthesia. Methods. After applying a spray to constrict the nasal mucosa,we used the MNT in 346 spontaneously breathing patients forthree indications: alone as an airway device during generalanaesthesia, to provide supplemental oxygen immediately afterextubation instead of by facemask, and to facilitate fibreopticintubation during general anaesthesia. Results. The device was successful for giving supplemental oxygenafter extubation (n=244) and facilitating fibreoptic intubation(n=28). When used as an airway for general anaesthesia, it wasonly successful without manipulation in 33 of 74 patients (45%).The MNT was easy to insert in awake patients. We encounteredsix complications: one MNT folded in the pharynx, and five patients(1.4%) experienced nosebleeds. Conclusions. The MNT was disappointing as a primary airway deviceunder general anaesthesia but was useful for giving oxygen afterextubation and for facilitation of fibreoptic intubation. Itcan cause nosebleeds. Br J Anaesth 2004; 92: 694–6     

Awake fibreoptic intubation, airway compression and lung collapse in a parturient: anaesthetic and intensive care management

A 28-year-old primigravida at 35 weeks gestation with acute onset of dyspnoea and stridor due to an intrathoracic neoplasm required semi-urgent caesarean section to allow diagnosis and treatment. Her inability to lie supine precluded regional anaesthesia. She underwent awake fibreoptic oral intubation followed by general anaesthesia. This was complicated by desaturation, high airway pressures, unilateral lung collapse, venous congestion and unexpected blood loss due to an undiagnosed placenta praevia.     

Difficult airway management patterns among attending anaesthetists practising in Israel

BACKGROUND AND OBJECTIVE: In recent years, a large number of airway devices have been introduced into clinical practice as adjuncts to the management of the difficult airway. The purpose of this study was to evaluate the practices of Israeli anaesthetists in specific clinical situations and their familiarity with the use of a variety of airway devices and techniques. METHODS: A survey developed in our institution was sent to 300 attending anaesthetists representing all board-certified anaesthetists practising in Israel. RESULTS: Of the 153 respondents, 75% belonged to university hospitals. Ninety-six percent were skilled with laryngeal mask airways and 73% with fibreoptics. Seventy percent preferred regional anaesthesia with anticipated difficult intubation, continuation of anaesthesia with a laryngeal mask with failed intubation and a laryngeal mask for impossible mask ventilation. For the airway scenarios, awake fibreoptic, awake direct laryngoscopy, intubation under inhalation anaesthesia and tracheostomy were shared equally. CONCLUSIONS: There is a high degree of adherence by Israeli anaesthetists to the American Society of Anesthesiologists' difficult airway algorithm. Current airway management practice patterns in Israel are presented.     

Angina bullosa haemorrhagica presenting as acute upper airway obstruction

We report a case of acute upper airway obstruction caused bya rapidly expanding blood-filled bulla in the oropharynx (anginabullosa haemorrhagica), requiring tracheal intubation. The larynxcould not be visualized by either awake fibreoptic laryngoscopyor direct laryngoscopy under anaesthesia. Surgical tracheostomywas therefore performed under general anaesthesia. Br J Anaesth 2004; 92: 283–6     

Intubation difficulties in patients with rheumatoid arthritis

Background : Fibreoptic intubation has been suggested to be the best method to manage a compromised airway. This retrospective study was designed to compare endotracheal intubation with the help of a rigid laryngoscope or a fibrescope in patients with rheumatoid arthritis.
Methods : Intubation difficulties with the laryngoscope and the fibrescope in patients with rheumatoid arthritis were investigated during a period of five and a half years. The anaesthesia records were used for analysis. The patients were divided into two groups (group I with 41 patients and group II with 37 patients) reflecting the change in the routine airway management in patients with rheumatoid arthritis in our hospital from the beginning of 1993. Before that time the patients were usually intubated orotracheally under general anaesthesia, but since 1993 rheumatoid patients with anticipated difficulties in endotracheal intubation have been preferably intubated fibreoptically awake under sedation and topical anaesthesia with a fibrescope.
Results : Major difficulties in endotracheal intubations were encountered in 13% of patients in group I and in 8% in group II. On two occasions in group I tracheostomy was needed. In one of these patients, emergency tracheostomy was performed. In the latter group, the main reason for prolonged fibreoptic intubations was lack of experience.
Conclusion : The introduction of fibreoptic intubation technique has had a favourable influence on the safety in the airway management of surgical patients with rheumatoid arthritis.     

Choice of anaesthesia for category‐1 caesarean section in women with anticipated difficult tracheal intubation: the use of decision analysis

A predicted difficult airway is sometimes considered a contra‐indication to rapid sequence induction of general anaesthesia, even in an urgent case such as a category‐1 caesarean section for fetal distress. However, formally assessing the risk is difficult because of the rarity and urgency of such cases. We have used decision analysis to quantify the time taken to establish anaesthesia, and probability of failure, of three possible anaesthetic methods, based on a systematic review of the literature. We considered rapid sequence induction of general anaesthesia with videolaryngoscopy, awake fibreoptic intubation and rapid spinal anaesthesia. Our results show a shorter mean (95% CI) time to induction of 100 (87–114) s using rapid sequence induction compared with 9 (7–11) min for awake fibreoptic intubation (p < 0.0001) and 6.3 (5.4–7.2) min for spinal anaesthesia (p < 0.0001). We calculate the risk of ultimate failed airway control after rapid sequence induction to be 21 (0–53) per 100,000 cases, and postulate that some mothers may accept such a risk in order to reduce potential fetal harm from an extended time interval until delivery. Although rapid sequence induction may not be the anaesthetic technique of choice for all cases in the circumstance of a category‐1 caesarean section for fetal distress with a predicted difficult airway, we suggest that it is an acceptable option.     

Gastric rupture after awake fibreoptic intubation in a patient with laryngeal carcinoma

An 86-yr-old man with recurrent laryngeal carcinoma developedgastric rupture after awake fibreoptic intubation before inductionof general anaesthesia. Early clinical signs included a distended,tense and tympanic abdomen with pain and massive pneumoperitoneum(chest radiograph). Laparotomy revealed a 4-cm longitudinalperforation along the lesser curvature of the stomach. Thiscase represents a rare but severe complication that may occurduring fibreoptic intubation in the awake patient.     

Awake oral fibreoptic intubation for caesarean section

A 35-week pregnant patient with ankylosing spondylitis and a known previous failed intubation required an elective caesarean section for intrauterine growth retardation. Regional anaesthesia was prevented by extensive spinal fusion. The anaesthetic management involved an awake oral fibreoptic intubation followed by induction and maintenance of general anaesthesia allowing delivery of a live infant without harm to the mother.     

Awake intubation and awake prone positioning of a morbidly obese patient for lumbar spine surgery

We describe the awake fibreoptic intubation followed by awake prone positioning of a woman weighing 180 kg with body mass index of 62 kg.m^?2 requiring emergency lumbar discectomy for cauda equina syndrome. This approach was taken to overcome difficulties in transfering an anaesthetised patient on to the operating table. Following topical anaesthesia with lidocaine and low‐dose remifentanil infusion, oral intubation was performed using a split oral airway to guide the fibrescope. The patient positioned herself on the Jackson operating table, following which general anaesthesia was induced. This technique optimised protection of the patient's eyes and other pressure areas while preventing undue cardiorespiratory compromise. The patient tolerated the procedure well, and later confirmed that she would consent to undergoing the same procedure again if further surgery became necessary.     

Awake videolaryngoscopy-assisted tracheal intubation of the morbidly obese

Awake videolaryngoscopy may be useful for the tracheal intubation of the morbidly obese. This prospective, observational study enrolled 50 patients undergoing bariatric surgery. After sedation and topical anaesthesia of the airway, awake tracheal intubation was attempted, assisted by videolaryngoscopy, and terminated if there was severe gagging, coughing, or inadequate laryngeal view. After three attempts the procedure was considered a failure. Twenty-seven intubations were successful on the first attempt, fifteen on the second, six on the third and two were not successful, giving a success rate of 96% (95% CI 86-100%). In one failure, inserting the tracheal tube caused severe gagging in spite of an adequate view of the larynx, and the trachea was intubated with the videolaryngoscope after induction of anaesthesia. The second failure was due to gagging, with subsequent tracheal intubation successful using fibreoptic bronchoscopy. When managing the morbidly obese airway, awake tracheal intubation using videolaryngoscopy may be considered.     

Cuffed oropharyngeal airway (COPA) as an adjunct to fibreoptic tracheal intubation

The cuffed oropharyngeal airway (COPA) was evaluated as an adjunct to oral and nasal fibreoptic tracheal intubation in 40 adult patients during general anaesthesia. Time from start to completion of intubation decreased rapidly with experience (median time 138 s). We conclude that the COPA may be a useful adjunct to fibreoptic tracheal intubation, allowing control and support of the airway during the procedure, using various anaesthetic techniques, in an acceptable amount of time. The ability to perform fibreoptic tracheal intubation while effectively supporting the airway using the COPA may be advantageous in managing the difficult airway and in trainee education.      

Awake fibrecapnic intubation in head and neck cancer patients with difficult airways: new findings and refinements to the technique

Recently, we described an adaptation of awake fibreoptic intubation that we call awake fibrecapnic intubation. The aim of this study was to evaluate the efficacy and risk of complications with this novel technique in a consecutive case series of head and neck cancer patients known to have difficult airways. We prospectively studied 40 consecutive intubations in head and neck cancer patients prior to a diagnostic or surgical procedure. Following topical anaesthesia, a flexible bronchoscope was introduced into the pharynx; spontaneous respiration was maintained in all patients. A special suction catheter was advanced into the airway through the suction channel of the bronchoscope for carbon dioxide measurements. When four capnograms were obtained, the bronchoscope was railroaded over the catheter and a tracheal tube was placed. All adverse events and complications were recorded. There were no complications associated with the technique. The median (range) time to intubation was 3 min (1.5-15 min). All patients were intubated successfully, 39 (98%) of them using awake fibrecapnic intubation. There was one patient with severe tumour bleeding and acute airway obstruction caused by advancement of the tube over the bronchoscope. This was not considered to be a complication of the fibrecapnic technique. Awake fibrecapnic intubation is a safe and valuable technique in head and neck cancer patients with a difficult airway.     

Management of difficult intubation in a patient with ankylosing spondylitis--a case report

We describe a case of difficult intubation in a patient suffering from ankylosing spondylitis undergoing total hip replacement surgery. The anesthetic management of 42 year old patient with difficult airway is discussed. Failure of epidural anesthesia procedure necessitated general anesthesia. The problems of performing awake fibreoptic intubation and other alternative techniques to secure the airway are described. Cervical spine involvement in ankylosing spondylitis is of great concern for the anesthetist. Longstanding progressive course of this disease leads to fibrosis, ossification and ankylosis of entire spine and sacroiliac joints. Cervical spine mobility is decreased and in severe cases total fixity occurs in a flexed position. Patient may also have atlanto-occipital and temporo-mandibular joint involvement as well. Cricoarytenoid cartilages involvement may result in upper airway compromise. Furthermore cervical spine vertebrae are prone to fractures, especially on hyperextension and may lead to spinal cord transection and quadriplegia. In this case report we describe the airway management of such patient with fixed rigidity of cervical spine and thoracolumbar kyphosis.     

Remifentanil as single agent to facilitate awake fibreoptic intubation in the absence of premedication

Remifentanil is increasingly being used as the primary agent to provide sedation during awake fibreoptic nasal intubation. In this observational study, we aimed to determine the optimal effect site concentration of remifentanil, using a target controlled infusion based on the Minto pharmacological model, to provide optimal safe intubation conditions without the use of other sedatives/premedication and/or spray-as-you-go local anaesthesia. Twenty patients with anticipated difficult airway participated in the study. Good intubating conditions were achieved in all patients with mean (SD) effect site concentration of 6.3 (3.87) ng.ml(-1) of remifentanil recorded at nasal endoscopy and 8.06 (3.52) ng.ml(-1) during tracheal intubation. No serious adverse event occurred during any of these procedures. These preliminary findings suggest that this is a feasible and safe technique for awake fibreoptic nasal intubation.