Conscious sedation for awake fibreoptic intubation: a review of the literature

Abstract

Purpose: Awake fibreoptic intubation (AFOI) is the gold standard of management of the predicted difficult airway. Sedation is frequently used to make the process more tolerable to patients. It is not always easy to strike a balance between patient comfort and good intubating conditions on the one hand and maintaining ventilation and a patent airway on the other. In the last 30 years, many drugs and drug combinations have been described, but there is very little in the literature to help guide the practitioner to choose between them. The objective of this article is to discuss the evidence supporting the use of the agents described with regard to their efficacy, recommended doses and techniques, and limitations to their use for AFOI.

Source: Publication databases were searched for articles published from 1996 to 2012 relating to sedation for AFOI.

Principle findings: Benzodiazepines, propofol, opioids, alpha2-adrenoceptor agonists, and ketamine are the main classes of drugs that have been described to facilitate AFOI. Drugs that are most suitable have a combination of both anxiolytic and analgesic properties. The ideal choice of drug may vary depending on the patient and the indication for AFOI.

Conclusion: There is good evidence to support the use of two drugs in particular, remifentanil and dexmedetomidine. Each has certain unique characteristics that make them an attractive choice for an AFOI.