A Retrospective Study of Success, Failure, and Time Needed to Perform Awake Intubation

Abstract

Background Awake intubation is the standard of care for management of the anticipated difficult airway. The performance of awake intubation may be perceived as complex and time-consuming, potentially leading clinicians to avoid this technique of airway management. This retrospective review of awake intubations at a large academic medical center was performed to determine the average time taken to perform awake intubation, its effects on hemodynamics, and the incidence and characteristics of complications and failure. Methods Anesthetic records from 2007 to 2014 were queried for the performance of an awake intubation. Of the 1,085 awake intubations included for analysis, 1,055 involved the use of a flexible bronchoscope. Each awake intubation case was propensity matched with two controls (1:2 ratio), with similar comorbidities and intubations performed after the induction of anesthesia (n = 2,170). The time from entry into the operating room until intubation was compared between groups. The anesthetic records of all patients undergoing awake intubation were also reviewed for failure and complications. Results The median time to intubation for patients intubated post induction was 16.0 min (interquartile range: 13 to 22) from entrance into the operating room. The median time to intubation for awake patients was 24.0 min (interquartile range: 19 to 31). The complication rate was 1.6% (17 of 1,085 cases). The most frequent complications observed were mucous plug, endotracheal tube cuff leak, and inadvertent extubation. The failure rate for attempted awake intubation was 1% (n = 10). Conclusions Awake intubations have a high rate of success and low rate of serious complications and failure. Awake intubations can be performed safely and rapidly.

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

“…Prediction of difficult airway management is unreliable , but there are common features that have been identified in patients requiring ATI. These include, but are not limited to: patients with head and neck pathology (including malignancy, previous surgery or radiotherapy); reduced mouth opening; limited neck extension; obstructive sleep apnoea; morbid obesity; and progressive airway compromise . There is limited evidence for any individual, validated, predictive assessment tool developed specifically for ATI.…”

“…Complications or unsuccessful ATI, although uncommon, should be prepared for , and immediate access to emergency drugs, staff and equipment is essential (Grade C). A plan for unsuccessful ATI, including possible postponement, FONA or high‐risk general anaesthesia, should be discussed explicitly and agreed on by all team members before beginning the procedure (Grade D).…”

The obstetric difficult airway: if we can't predict it, can we prevent it?

“…In such patients, awake fibreoptic intubation is often considered the ‘gold standard’ because it preserves both consciousness and ventilation. The failure rate is low, approximately 1–2% , although there is a 5% chance for airway compromise secondary to local anaesthetic use. For the category 1 cesarean section though, awake fibreoptic intubation is not an apt choice considering the estimated 7–11 min it takes to secure the airway .…”

Current practice for awake fibreoptic intubation - asking the right questions

“…As El-Boghdadly et al and Murphy and Howes [3] observe, training in AFOI is advisable for all anaesthesia trainees, and their study's detailing of the grades of trainee performing AFOI, together with their complication rates, is a useful addition to the literature. Our own 2015 retrospective study of 1554 AFOIs, also at a tertiary care teaching centre, included AFOIs performed by attending consulting staff or their trainees under supervision [4], as did Joseph et al's retrospective analysis of AFOI, in which specific mention was made of resident involvement in 1038 of the 1085 cases reported [5]. With an incidence of only 1-2% of tracheal intubations requiring AFOI, we agree with El-Boghdadly et al's point that every opportunity must be taken to train anaesthetists in the technique in teaching institutions.…”

“…We thank the authors for contextualising our prospective data with retrospective results collected in the USA [4] and Canada [5]. Retrospective data points can be under-reported, and the low complication rates reported by Joseph et al [4] could be an inaccurate representation of their true incidence. Moreover, the comparable complication rates provided by Law et al [5] might also be underreported.…”