The emerging role of awake videolaryngoscopy in airway management

Abstract

This editorial accompanies an article by Alhomary et al., Anaesthesia 2018; 73: 1151-61. Awake fibreoptic intubation has been considered the technique of choice when managing many types of predicted difficult airway. In principle, if a patient is maintaining the patency of their own airway, there is a margin of safety which is lost if general anaesthesia is induced before the trachea is intubated. Despite this, the Fourth National Audit Project of the Royal College of Anaesthetists (NAP4) reported that awake fibreoptic intubation was not used as the primary airway plan for many highrisk patients [1]. However, awake fibreoptic intubation is a complex skill requiring regular practice to maintain competence. It is easy to see how this potentially difficult task, performed on a high-risk patient group, in departments where numbers of awake fibreoptic intubations may be low, may pose a problem; and in consequence, it is understandable that an anaesthetist might opt for a more familiar, but less appropriate, technique [1]. It is of course also true that awake fibreoptic intubation is not suitable for tracheal intubation in all patients with airway problems, and it is not always successful; NAP4 demonstrated that it failed for a variety of reasons. Most commonly these were airway obstruction, lack of patient co-operation and difficulty recognising airway anatomy due to excess secretions, blood or suction failure [1]. Changing practiceThe NAP4 was published in 2011. However, anaesthetic practice is ever changing. In 2016, Ahmad and Bailey argued in this journal that awake fibreoptic intubation was becoming obsolete [2]. Later that year, reviewing the revised Difficulty Airway Society's (DAS) guidelines on difficulties in intubation, Marshall and Pandit suggested that "if it is essential to maximise the first attempt success rate, and if it is the case that videolaryngoscopes yield higher success in visualising the glottis, then it follows that these should become first-line devices in most if not all tracheal intubations" [3]. A Cochrane systematic review of videolaryngoscopy compared with direct laryngoscopy in adults concluded that "failed intubations were significantly fewer when videolaryngoscopy was used in participants with anticipated difficult airway." [4], although a similar review found no evidence of benefit in children [5]. In addition to this, the recent DAS guidelines on intubation in critically ill adults acknowledge the role of videolaryngoscopy [6], stating that "if difficult laryngoscopy is predicted then videolaryngoscopy should be considered from the outset". However, these publications deal largely with the management of intubation in patients who are anaesthetised. This month's issue of Anaesthesia presents a systematic review comparing awake videolaryngoscopy and awake fibreoptic intubation in patients with anticipated airway difficulty [7]. Using standard systematic review methodology, the authors included eight studies overall. One study could not be included in the quantitative meta-analysis,...

Experience in awake fibreoptic intubation: a reply

“…Hence, training in awake VL will lend itself well to awake FB training. Additionally, there have been calls for awake VL to become a core anaesthetic skill [2] as a recent meta-analysis demonstrated a similar success rate and safety profile compared with FB [3], and we support the notion that more of these should be incorporated into training. Obtaining and maintaining competence in the procedural skill of awake VL is readily achievable, as the technique is more similar to the asleep approach than FB and therefore more readily practiced.…”

Difficult airway management algorithms: a directed review

“…Currently, DAS are finalising guidelines for the management of the predicted difficult airway in adults with awake tracheal intubation . These guidelines may be helpful in further defining the role of awake videolaryngoscopy compared with flexible bronchoscopic intubation, and perhaps a future universal algorithm could allow for a choice between these two techniques.…”

Awake tracheal intubation for blunt airway trauma

“…Awake videolaryngoscopy is an alternative strategy for tracheal intubation before induction of general anaesthesia and its increasing recognition in the literature mirrors the familiarity with these devices shown by both trainees and consultants . Alongside increasing familiarity, other advantages when compared with the use of a flexible bronchoscope include reduced time to tracheal intubation, improved anatomical views and a degree of flexibility with regards to tracheal tube size and type . Both modalities appear to have similar failure rates .…”

“…Both modalities appear to have similar failure rates . Although videolaryngoscopes may usefully allow for manipulation of the airway, for example, by upward traction during intubation, which may increase the space above the swollen, pathological larynx, this potential advantage was negated by the desire to avoid undue manipulation of the airway . Use of a flexible bronchoscope has a documented low incidence of airway trauma (0.7%), although a systematic review found no compelling evidence that either method is associated with fewer complications .…”