Awake tracheal intubation in anticipated difficult airways: LMA Fastrach vs flexible bronchoscope: A pilot study

Abstract

Study objective: To compare the use of LMA Fastrach intubating laryngeal mask airway (ILMA) to flexible bronchoscopy (FB) for awake intubation in patients with difficult airways.

Design: Randomized prospective study.

Setting: Large academic medical center.

Patients: Forty adult patients, American Society of Anesthesiologists I-IV, meeting the criteria for awake intubation based on history and physical examination.

Interventions: After sedation and airway topicalization, patients were randomized to either FB group, n=19, or ILMA group, n=21. All intubations were performed by or under the supervision of an attending anesthesiologists, with variable participation of residents or certified registered nurse anesthetists. A maximum of three attempts were permitted with the assigned technique, to be followed by the alternative method in case of failure.

Measurements: Times to carbon dioxide (end-tidal carbon dioxide) detection, endotracheal tube placement, number of attempts, training level of operator, and adverse events were recorded. Blood pressure, oxygen saturation, and heart rate were measured. Patients were interviewed the following day regarding their experience and satisfaction.

Main results: Overall intubation success rate within three attempts was 95% for both groups. However, successful intubation on the first attempt occurred at a significantly higher rate with ILMA vs FB (95% vs 58%; P=.0028). Total mean time to endotracheal tube placement was also significantly shorter in the ILMA group vs FB (92 vs 246 seconds; P=.0001). There were no adverse events in either group, and patient satisfaction was not significantly different.

Conclusion: Awake intubation can be performed successfully and expeditiously with the use of LMA Fastrach in patients with a difficult airway and no contraindication to a blind technique. It compared favorably to the use of the fiberoptic bronchoscope in the patient cohort presented in this study.

Keywords: Airway management; Anticipated difficult airway; Awake Intubation; Awake fastrach intubation; Awake intubation; Difficult airway management; Fastrach intubation in comparison with fiberoptic bronchoscope; Intubation techniques.