Acute Awake Fiberoptic Intubation in the ICU in a Patient with Limited Mouth Opening and Hypoxemic Acute Respiratory Failure

Abstract

The incidence and survival of patients with head-and-neck cancer have been on the increase for decades. Following surgery or radiation therapy, complications such as difficult airways may evolve. These difficult airways may be unique and not manageable with conventional intubation methods as well as video laryngoscopes. Acute awake fiberoptic intubation may be a feasible option also for urgent emergency airway management of known difficult airways. The “cannot intubate–cannot oxygenate” (CI–CO) situation has to be avoided at all costs, since emergency cricothyrotomy has a fail ratio of more than 50% when performed by an anesthesiologist.

Managing Known Difficult Airways in Obstetric Patients Using a Flexible Bronchoscope and IRRIS: A Case-Illustrated Guide for Nonexpert Anesthesiologists, without Surgical Backup

“…e most important aspect is through testing (including dermatomal level) and extreme caution to identify and avoid a high block [1]. Some patients cannot be intubated with a hyperangulated videolaryngoscope [4,8,20], and in case of failed (or impossible) neuraxial anesthesia, awake tracheal intubation with a FB is the primary choice if rescue invasive techniques are to be avoided [4,8]. e advantages of an awake patient are that a patent airway is preserved (with the largest possible airway diameter due to preserved intrinsic airway muscle tone), spontaneous breathing is preserved (hence oxygenation), the glottic opening is easier to localize (air bubbles) and easier to intubate (naturally aligned oropharyngeal axis), the patient can be sitting (thus avoiding aortocaval compression), and there is some protection against aspiration [4,5].…”

“…Some common features among nonpregnant and pregnant patients in general, where airway management can be predicted to be very difficult and for whom awake tracheal intubation should be considered, are (1) previous difficult airway, (2) significant neck pathology, (3) severely reduced mouth opening, and (4) severely reduced neck movements. Neck pathology from tumor, previous surgery, or radiation increases the risk of failure in every aspect of airway management [4][5][6][7][8]. Mouth opening is normally 40−60 mm depending on gender, height/weight, age, and ethnicity [9].…”

Use of the flexible bronchoscope and Infrared Red Intubation System in a known difficult airway in the Intensive Care Unit

“…Some patients cannot be intubated with a hyperangulated videolaryngoscope (HA-VL). [1][2][3][4] This case-report describes a patient in respiratory failure requiring acute intubation, with previous impossible HA-VL intubation. If invasive techniques are to be avoided, acute Awake Tracheal Intubation with a Flexible Bronchoscope (ATI-FB) may be the best option.…”

Diagnosis and management of temporomandibular joint dysfunction before surgery: a case report

“…As deaths due to trismus after induction of anaesthesia have been already reported, we should develop strategies to manage difficult intubation cases. 1 Especially, it is safer to perform general anaesthesia after improving trismus.…”