Abstract
Background: Current guidelines recommend fiberoptic intubation as the gold standard for intubating patients with “difficult airways.” An awake, spontaneously breathing patient provides some degree of safety; however, many patients require sedation. Sedation may impair spontaneous breathing and counteract the benefits of an “awake fiberoptic intubation.” Sevoflurane might be an alternative to intravenous sedative drugs as it preserves spontaneous breathing and provides patient comfort. For this, we implemented a sevoflurane-based protocol to improve the safety of fiberoptic intubation in high-risk patients with severe comorbidities.Methods: We enrolled 29 patients with pharyngeal or laryngeal carcinoma who had undergone fiberoptic intubation with sevoflurane due to a “difficult airway.” The primary endpoint was the preservation of spontaneous breathing during airway management. Secondary endpoints were drop in oxygen saturation to < 90%, the success rate and duration of intubation, the use of intravenous sedative drugs, changes in vital parameters, complications, and awareness. Results: Preservation of spontaneous breathing was possible in all procedures. Fiberoptic intubation was successful in 25 procedures. In three cases, a video laryngoscope was used. One patient suffering from an unidentified trans-cricoid fistula exhaled sevoflurane before an adequate depth of sedation was achieved. In this patient, oxygen saturation dropped to 71%. In the other 28 patients, oxygen saturation did not drop below 90%. The vital parameters did not change significantly. One fiberoptic intubation was complicated by epistaxis, and four patients had moderate bronchial spasm. None of the patients were able to recall the procedure. Conclusions: We concluded that a sevoflurane-based fiberoptic intubation in patients with “difficult airways” and relevant comorbidities is technically feasible. A trans-cricoid fistula is probably a contraindication for this approach.
Intubating a Treacher Collins Syndrome patient with STRIVE Hi and videolaryngoscopy
