Awake nasotracheal intubation with a 300-mm working length fiberscope: a prospective observational feasibility trial

Abstract

Background: Awake fiberoptic tracheal intubation is an established method of securing difficult airways, but there are some reservations about its use because many practitioners find it technically complicated, time-consuming, and unpleasant for patients. Our main goal was to test the safety and efficacy of a 300-mm working length fiberscope (video rhino-laryngoscope) when used for awake nasotracheal intubation in difficult airway cases.

Methods: This was a prospective, single-center study involving adult patients, having an ASA physical status between I and IV, with laryngopharyngeal pathology causing distorted airway anatomy. Awake nasotracheal intubation, using topical anesthesia and light sedation, was performed using a 300 mm long and 2.9 mm diameter fiberscope equipped with a lubricated reinforced endotracheal tube. The primary outcomes were the success and duration of the procedure. Patients' periprocedural satisfaction and other incidents were recorded.

Results: We successfully intubated all 25 patients included in this study. The mean ±SD duration of the procedure, starting from the passage of the intubating tube through one of the nostrils until the endotracheal intubation, was 76 ± 36 seconds. Most of the patients showed no discomfort during the procedure with statistical significance between the No reaction Group with the Slight grimacing Group (95%CI 0.13, 0.53, p = 0.047) and the Heavy grimacing Group (95%CI 0.05, 0.83, p = 0.003). The mean ±SD satisfaction score 24 hours post-intervention was 1.8 ± 0.86 - mild discomfort. No significant incidents occurred.

Conclusions: Our study showed that a 300-mm working length flexible endoscope is fast, safe, and well-tolerated for nasotracheal awake intubation under challenging airways.

Keywords: Airway management; Endoscopy; Endotracheal intubation; Local anesthesia; Patient satisfaction.

Figure 1

The fiber rhino-laryngoscope armed with a 6.0 reinforced intubating tube. The articulated tip is continuing the tube, guiding it through the nasal passage until the trachea.

Figure 2

Some of the challenging cases. A) Glottis tumor, B) Laryngeal tumor in a subject associating ankylosing spondylitis, C) Epiglottic cyst, D) Base of tongue tumor.