A Nontraditional Approach for Awake Fiberoptic Nasotracheal Intubation. A Randomized Controlled Superiority Trial

A nontraditional approach for awake fiberoptic nasotracheal intubation. A randomized controlled superiority trial Introduction It takes skill and specialized equipment to intubate someone with an anticipated difficult airway. The American Society of Anaesthesiologists and other European authors advise awake fiberoptic intubation (FOB). An awake patient can protect the airway. When a patient breathes independently until the airway is secured, awake fiberoptic intubation increases safety. In addition to requiring awake flexible fiberoptic intubation, difficult airway instances such as limited jaw mobility, restricted mouth opening, surgical interventions, or procedures planned in the oral cavity also require the nasotracheal route for intubation. Compared to oral intubation, nasal intubation is typically more straightforward and more successful.

Negotiating the endotracheal tube can be challenging since initial resistance is experienced during the passage of the bronchoscope and endotracheal tube (ET). However, the nasal approach gives an aligned airway to the larynx and trachea and holds the tube more stably. Gentle force is needed to overcome this resistance, which could cause the nose passage's friable mucosa to bleed. Coughing during a flexible fiberoptic bronchoscopy can make it difficult to see the vocal cord because bleeding in the nasopharynx and oropharynx can irritate the airway and cause coughing.

Berman and Ovassapian airways are available to help with awake flexible fiberoptic intubation via oral route. These airways provide a passageway for the ET tube and bronchoscope. However, the nasal approach does not have access to such an airway. A fiberoptic bronchoscope is usually passed through the more patent nostril to reach the nasopharynx. It then follows the main nasal pathway at the nose floor along the superior aspect of the hard palate and the lateral aspect of the nasal septum inferior to the lower turbinate. Once there, the operator can identify the pharyngeal structures, such as the base of the tongue and the epiglottis, which are primarily "in-fall" and prevent clear views of the larynx, necessitating a jaw thrust to visualize the laryngeal structures for patients who are scheduled to be intubated under general anesthesia so a wake fiberoptic is preferred in anticipating difficult airway.

An endotracheal tube (ET) can be inserted along the FOB cable that has already advanced into the trachea, making FOB nasal intubation easier and faster. This is achieved by inserting a modified split tube nasally down to or near the larynx, which allows the FOB cable to be immediately in front of the larynx without the need to confirm the anatomical details of the nasopharyngeal-laryngeal journey required during classic nasal FOB intubation.

This study hypothesized that awake nasotracheal fiberoptic intubation through an endotracheal tube inserted in the nasopharynx would be quick and have fewer complications than the conventional technique. This study compares the time to intubation and safety of FOB nasal intubation as classically done and thorough endotracheal tube.