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(searched for: (title:(Combined Techniques in Difficult Airway Management)
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Geoffrey Haw Chieh Liew, Theodore Gar Ling Wong, Anqi Lu, Harikrishnan Kothandan
Proceedings of Singapore Healthcare, Volume 24, pp 117-120; doi:10.1177/201010581502400208

Abstract:
Indirect laryngoscopy, in the form of flexible fibrescopy remains the gold standard in the management of predicted difficult intubation. In the last decade, indirect laryngoscopy in the form of videolaryngoscopy has quickly gained popularity as a tool in the anaesthetists' armamentarium in difficult airway management. We describe a case of successful intubation in a difficult airway with the combination of both videolaryngoscopy and flexible fibrescopy when attempts with other commonly used techniques failed.
, Veena Chatrath, Radhe Sharan, Anju Bala, Ranjana, Sudha
Published: 1 January 2016
Anesthesia: Essays and Researches, Volume 10, pp 255-261; doi:10.4103/0259-1162.171443

Abstract:
To evaluate the efficacy, hemodynamic changes, and patient comfort during awake fiberoptic intubation done under combined regional blocks. In the present observational study, 50 patients of American Society of Anesthesiologists ( ASA) Grade I–II, Mallampati Grade I–IV were given nerve blocks - bilateral glossopharyngeal nerve block, bilateral superior laryngeal nerve block, and recurrent laryngeal nerve block before awake fiberoptic intubation using 2% lidocaine. Procedure was associated with minimal increases in hemodynamic parameters during the procedure and until 3 min after it. Most of the intubations were being carried out within 3 min. Patient comfort was satisfactory with 90% of patients having favorable grades. The most common cause of mortality and serious morbidity due to anesthesia is from airway problems. One-third of all anesthetic deaths are due to failure to intubate and ventilate. Awake flexible fiberoptic intubation under local anesthesia is now an accepted technique for managing such situations. In awake patient's anatomy, muscle tone, airway protection, and ventilation are preserved, but it is essential to sufficiently anesthetize the upper airway before the performance of awake fiberoptic bronchoscope-guided intubation to ensure patient comfort and cooperation for which in our study we used the nerve block technique. A properly performed technique of awake fiberoptic intubation done under combined regional nerve blocks provides good intubating conditions, patient comfort and safety and results in minimal hemodynamic changes.
Lingmin Chen, Jin Liu, Jing Yang, Yanzi Zhang, Yue Liu
Regional Anesthesia & Pain Medicine, Volume 41, pp 158-163; doi:10.1097/aap.0000000000000350

The publisher has not yet granted permission to display this abstract.
, Francesco Sgalambro, Giuseppe Chiaramonte, Cristina Santonocito, Gaetano Burgio, Antonio Arcadipane, Irccs-Ismett (Istituto Mediterraneo Per I Trapianti E Terapie Ad Alta Specializzazione) “Renato Fiandaca” Simulation Center
Turkish Journal of Anaesthesiology and Reanimation, Volume 47, pp 464-470; doi:10.5152/tjar.2019.99234

The publisher has not yet granted permission to display this abstract.
Mee Young Chung, Byunghoon Park, Jaeho Seo,
Korean Journal of Anesthesiology, Volume 71, pp 232-236; doi:10.4097/kja.d.18.27203

Abstract:
Huge goitor can lead to tracheal compression and hence difficulty in intubation. This is compounded by severe obesity. Failed tracheal intubation in difficult intubation is a serious event that may lead to increased patient morbidity and mortality. Current intubation rescue techniques and combination of different rescue techniques may increase the success rate of difficult intubation. In a 47-year-old female patient, with severe obesity and a huge goiter, our attempts at intubation using direct laryngoscope, video laryngoscope, and awake fiberoptic bronchoscope had failed. We succeeded by applying video laryngoscope to improve visualization of the airway and fiberoptic bronchoscope as a stylet for endotracheal tube.
Pui-San Loh, Kevin Wei Shan Ng
Journal of Anaesthesiology Clinical Pharmacology, Volume 33, pp 254-255; doi:10.4103/0970-9185.209738

Abstract:
Airway management for patients with recent oral facial injuries is always a challenge for the anesthetist. We describe how the glidescope (GLS) and fiber-optic (FOB) can be effectively combined in three patients undergoing oral maxillofacial surgeries after sustaining multiple facial fractures from trauma to allow less traumatic intubation, an option to visualize on either monitor and faster intubating time (mean 1 min 14 s for our cases) compared to the use of either one alone. Although it allows for better visualization of the vocal cords, it requires 2 trained anaesthetists to perform and this would need to be considered when using this technique.
Kemal Tolga Saracoglu
Global Journal of Anesthesiology pp 001-002; doi:10.17352/2455-3476.000006

Abstract:
Journal of Addiction Medicine and Therapeutic Science is an international, open access, a peer reviewed academic and distinguished journal which covers the outstanding and most update research works/peak quality papers on related to clinical prevention and treatment to harmful alcohol, tobacco, and other drug use diagonally the spectrum of clinical settings.
Nupur Moda, Niraj Kumar
Asian Journal of Pharmaceutical and Clinical Research, Volume 11, pp 1-3; doi:10.22159/ajpcr.2018.v11i11.27199

Abstract:
Airway management may be difficult in patients with fixed cervical spine who have undergone previous spine surgery. Among the various techniques, fiber-optic intubation is a preferred method for securing the airway in such situation. However, it has some limitations also like identification of landmarks, especially in a case of distorted anatomy of the airway. To overcome this inadequacy, we used video laryngoscopy as a complement, to guide the tip of bronchoscope beneath the epiglottis into the trachea and thus achieving the goal. We present a case of difficult airway of fixed cervical spine with distorted anatomy in which combined use of fiberoptic and video laryngoscopy was performed to secure the airway. In our opinion, this technique can be utilized for other difficult airway case scenario also.
Nobuhiro Saruki, Shigeru Saito, Jun Sato, Toshifumi Takahashi, Ryuji Tozawa
Journal of Anesthesia, Volume 15, pp 132-135; doi:10.1007/s005400170013

The publisher has not yet granted permission to display this abstract.
Pei-Shing Hsieh, Hon-Ping Ma, Chung-Shun Wong, Jiann Ruey Ong
The Journal of Emergency Medicine, Volume 54, pp 674-677; doi:10.1016/j.jemermed.2018.02.010

The publisher has not yet granted permission to display this abstract.
Yafen Liang, William R. Kimball, Robert M. Kacmarek, Warren M. Zapol, Yandong Jiang
Anesthesiology, Volume 108, pp 998-1003; doi:10.1097/aln.0b013e318174f027

The publisher has not yet granted permission to display this abstract.
Mohamed Elsayed Hassan, Essam Mahran
Published: 1 January 2017
Saudi Journal of Anaesthesia, Volume 11, pp 196-202; doi:10.4103/1658-354X.203013

Abstract:
Awake fiberoptic intubation (AFOI) is one of the principal techniques in the management of difficult airway in oral cancer surgery. We hypothesized that the addition of a small dose of fentanyl could improve the sedative criteria of dexmedetomidine during AFOI technique, without the need to increase the dose of dexmedetomidine which may be associated with airway compromise. One hundred and fifty American Society of Anesthesiologists physical status 1 and 2 patients planned for AFOI for oral cancer surgery patients were allocated into three groups (fifty patients each). Group D1: Received an infusion of 1 μcg/kg dexmedetomidine diluted in 50 ml saline over 20 min. Group D2: Received an infusion of 2 μcg/kg dexmedetomidine diluted in 50 ml saline over 20 min. Group DF: Received an infusion of 1 μcg/kg dexmedetomidine added to 1 μcg/kg fentanyl diluted in 50 ml saline over 20 min. AFOI was done by topical anesthesia and with the same technique in all patients. All patients were assessed for: airway obstruction, intubation scores (vocal cord movement, coughing, and limb movement), fiberoptic intubation scores, and hemodynamic variables. Any episode of bradycardia or hypoxia was recorded and managed. Group D2 showed more incidence of airway obstruction than the other two groups. Limb movement scores were more in Group D1 compared to the other two groups. All groups were comparable as regard fiberoptic intubation scores, coughing, and vocal cord opening scores. Adding a low dose of fentanyl (1 μcg/kg) to a low dose of dexmedetomidine can prevent the risk of airway obstruction associated with increasing the dose of dexmedetomidine while achieving the same favorable intubation scores.
David Zarabanda, Enrico Danzer, Tulio A. Valdez,
Published: 1 December 2019
Videoscopy, Volume 29; doi:10.1089/vor.2019.0610

The publisher has not yet granted permission to display this abstract.
B. Madhusudhana Rao, S. Manikandan
17th Annual Conference of Indian Society of Neuroanaesthesiology and Critical Care, Volume 3; doi:10.1055/s-0038-1667567

Abstract:
Background: Awake fibreoptic intubation (AFOI) is the gold standard for anticipated difficult airway management. If improperly done, there could be loss of airway or compressing the already compromised cervical cord and worsening of neurological status. We hypothesised that there are no differences in the intubation conditions produced with either dexmetomidine infusion alone or a combination of propofol with fentanyl infusion using bispectral index (BIS) guided sedation (target 70) for AFOI using ‘spray as you go (SAYGO)’ technique in patients coming for elective neurosurgical procedures with anticipated difficult airway. Methodology: Forty adult neurosurgical patients requiring awake fibreoptic bronchoscope intubation were enrolled and randomly divided into two groups. Group D (dexmedetomidine) received a loading dose (LD) −1 mcg/kg over 10 min and 0.5 mcg/kg/h infusion till target BIS. Group PF (propofol with fentanyl), propofol received LD at 1 mg/kg/h with fentanyl 1 mcg/kg over 10 min and 1 mg/kg/h and 1 mcg/kg infusion, respectively, till target BIS. AFOI with SAYGO technique was performed followed by post-intubation neurological examination. Results: The demographic data, vitals, cough severity, lignocaine dose and post-operative recall was not significant. The BIS value at 9 and 12 min and time taken to achieve target BIS was statistically significant. BIS and OAA/S had good correlation. Total intubation score is better in Group PF than Group D. Discussion: Propofol with Fentanyl combination provided better AFOI condition than dexmedetomidine with shorter intubating time, better intubation score and post-operative profile with SAYGO technique. Both BIS and observer’s assessment of awareness/sedation OAA/S are reliable indicators of sedation. Blinded could not be possible and small sample size were the limiting factors.
, Alessandro Ribechini, Fabio Guarracino
Cardiovascular Ultrasound, Volume 18, pp 1-3; doi:10.1186/s12947-020-00208-z

Abstract:
Pulmonary embolism (PE) is a life-threatening disease difficult to diagnose and manage in severe hemodynamic unstable patients. Transoesophageal echocardiography (TEE) is considered useful to improve diagnosis, but such approach has physical limitations for the interposition of the airways preventing the clear assessment of the left pulmonary artery. Endobronchial ultrasound (EBUS), a recently developed technique carried out using a modified bronchoscope having a small ultrasound convex probe at the tip allowing to perform ultrasonography examination of the mediastinum, can extensively visualize the pulmonary arteries on both sides. We present the first use of EBUS to rapidly diagnose and subsequently treat a 64 years old woman with history of lateral amyotrophic sclerosis admitted to the intensive care unit (ICU) for severe dyspnoea and rapidly experiencing a cardiac arrest. Combined bedside EBUS and echocardiography allowed to rapidly diagnose the cause of cardiac arrest and avoid risks related to transferring the critical patient to the radiology department.
A Fibbi, , F Brocchetti, M Peirano, G Garaventa, A Presta, F Baricalla
Published: 1 June 2002
Acta Otorhinolaryngologica Italica, Volume 22

The publisher has not yet granted permission to display this abstract.
Chunzhu Li, Jiali Peng, Yu Sun, Rong Hu, Hao Wang, Jia Yan, Hong Jiang
Published: 5 March 2020
Abstract:
Background: Awake fiberoptic bronchoscope intubation (AFOBI) is the gold standard technique for the management of patients with difficult airways. Adequate sedation and analgesia are essential for successful AFOBI. The aim of this study was to evaluate the sedative and analgesic validity and administration routes of dexmedetomidine and fentanyl combined with ketamine in awake fiberoptic intubation. Methods: Patients undergoing head and neck surgery under general anesthesia with predicted difficult airways were included. Participants were randomly assigned to 6 different groups (n=6): groups 1-3 were intravenous (IV), while groups 4-6 were intranasal(IN) (group 1: dexmedetomidine (DEX) 1 μg/kg + fentanyl (FEN) 1 μg/kg; groups 2-3: DEX 1 μg/kg+ FEN 0.7 μg/kg + ketamine (KTM) 0.1/0.2 mg/kg; group 4: DEX 1.5 μg/kg + FEN 1.4 μg/kg; and groups 5-6: DEX 1 μg/kg + FEN 1 μg/kg + KTM 0.4/0.6 mg/kg). The visual analog scale (VAS) score during intubation, time required for the modified observer’s assessment of alertness/sedation scale (OAA/S) score to reach above 2 and for the bispectral index (BIS) to decrease to 60-80, motor activity assessment scale (MAAS) score, changes in vital signs and adverse effects were recorded. Results: Among the IV groups, the VAS score of group 1 (5.65±2.11) was higher than those of group 2 (1.89±2.16, P =0.012) and group 3 (1.15±0.98, P =0.001). Among the IN groups, the VAS score was lower in group 6 (0.86±1.27) than in group 4 (7.20±2.70, P
Pooja Singh, Noor Bano, Dheer Singh, Tallamraju Prabhakar
Published: 1 January 2019
Anesthesia: Essays and Researches, Volume 13, pp 539-546; doi:10.4103/aer.AER_64_19

Abstract:
Awake fiberoptic intubation (AFOI) is the gold standard technique for managing patients with anticipated difficult airway. Conscious sedation is desirable, not only to make the procedure more tolerable and comfortable for the patient but also to ensure optimal intubating conditions. Ideal sedation regime for AFOI should provide comfort, cooperation, hemodynamic stability, and amnesia along with maintenance of spontaneous respiration. Several sedative agents have been assessed over the past two decades for this purpose but α2 agonists appear to be the favorable choice owing to its sedative, analgesic, amnestic, and sympatholytic properties along with good hemodynamic profile. The present study has been aimed to recognize the characteristics of dexmedetomidine, clonidine, and midazolam and to compare their efficacy in providing optimal intubating conditions as well as hemodynamic stability during AFOI. A prospective double-blind randomized study done in tertiary care hospital. Sixty patients of American Society of Anesthesiologists physical status Classes I and II aged 18-60 years with anticipated difficult airway were randomly allocated into three groups. All the patients received injection midazolam bolus followed by sedation infusion of midazolam, dexmedetomidine, and clonidine according to the allocated group. Primary outcome includes the time to achieve Ramsay Sedation Score (RSS) ≥2, time taken in intubation, intubation score, comfort score for fiberoptic insertion and intubation, and patient tolerance after intubation. The secondary outcome was hemodynamic, and respiratory variables include changes in heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO2), and respiratory rate during the procedure. All data were recorded, summarized, tabulated, and statistically analyzed using SPSS 16.0 version (Chicago, Inc., USA). The data were presented in mean ± standard deviation. P < 0.05 was considered as statistically significant. All the three groups were comparable in terms of demographic profile. Time to achieve RSS ≥2 and mean intubation time was significantly less in Groups D and C as compared to Group M (P < 0.001). Among groups, Group D took least time to achieve RSS ≥2 (5.53 ± 0.74) and mean intubation time (4.53 ± 0.91). Similarly, overall intubation score, comfort, and patient tolerance score were significantly more in Group M as compared to Groups D and C (P < 0.001). Among the groups, Group D achieved least intubation score (3.80 ± 0.67) and comfort score (2.53 ± 0.74). Although Groups D and C have a lower mean HR and MAP during the procedure and intubation compared to Group M, the incidence of SpO2 is most frequent with clonidine. Patients who received α2 agonist were calmer and cooperative with less pain and discomfort than the patients who received midazolam. Dexmedetomidine allows better endurance, stable hemodynamics, and patent airway as compared to clonidine.
Chunzhu Li, Jiali Peng, Yu Sun, Rong Hu, Hao Wang, Jia Yan, Hong Jiang
Published: 10 April 2020
Abstract:
Background: Awake fiberoptic bronchoscope intubation (AFOBI) is the gold standard technique for the management of patients with difficult airways. Adequate sedation and analgesia are essential for successful AFOBI. The aim of this study was to evaluate the sedative and analgesic validity and administration routes of dexmedetomidine and fentanyl combined with ketamine in awake fiberoptic intubation.Methods: Patients undergoing head and neck surgery under general anesthesia with predicted difficult airways were included. Participants were randomly assigned to 6 different groups (n = 6): groups 1-3 were intravenous (IV), while groups 4-6 were intranasal (IN) (group 1: dexmedetomidine (DEX) 1 μg/kg + fentanyl (FEN) 1 μg/kg; groups 2-3: DEX 1 μg/kg + FEN 0.7 μg/kg + ketamine (KTM) 0.1/0.2 mg/kg; group 4: DEX 1.5 μg/kg + FEN 1.4 μg/kg; and groups 5-6: DEX 1 μg/kg + FEN 1 μg/kg + KTM 0.4/0.6 mg/kg). The visual analog scale (VAS) score during intubation, time required for the modified observer’s assessment of alertness/sedation scale (OAA/S) score to reach above 2 and for the bispectral index (BIS) to decrease to 60-80, motor activity assessment scale (MAAS) score, changes in vital signs and adverse effects were recorded.Results: Among the IV groups, the VAS score of group 1 (5.65 ± 2.11) was higher than those of group 2 (1.89 ± 2.16, P = 0.012) and group 3 (1.15 ± 0.98, P = 0.001). Among the IN groups, the VAS score was lower in group 6 (0.86 ± 1.27) than in group 4 (7.20 ± 2.70, P < 0.001) and group 5 (3.93 ± 2.73, P = 0.031). Participants in group 5 and group 6 were less likely to cough when intubated than those in group 4 (P = 0.002), while the differences among IV groups were not significant. There were no significant differences in the other endpoints.Conclusions: Our study indicates that the addition of subanesthetic doses of ketamine, either intravenous or intranasal, could reduce the fentanyl and dexmedetomidine consumption used in AFOBI and provide better sedative and analgesic effects.Trial registration: Chinese Clinical Trial Registry (www.chictr.org.cn; ChiCTR1900021185), prospectively registered on February 1st, 2019.
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