Comparison of Enk Fibreoptic Atomizer with translaryngeal injection for topical anaesthesia for awake fibreoptic intubation in patients at risk of secondary cervical injury: A randomised controlled trial.

BACKGROUND: Two methods of topical anaesthesia for awake fibreoptic intubation (FOI) in patients at risk of secondary cervical injury were compared: the translaryngeal injection (TLI) technique and the Enk Fibreoptic Atomizer. OBJECTIVE: The objective of this study was to determine which system of topical anaesthesia provides the fastest and most comfortable awake FOI, using the oral approach. DESIGN: A randomised controlled study. SETTING: A single centre trial between 2009 and 2011. PATIENTS: One hundred and twenty patients (63 women, 57 men) who underwent neurosurgery of the spine at Klinikum St. Georg Leipzig were randomly allocated into two groups (group TLI, 61 patients; group ENK-ATOMIZER, 59 patients). Inclusion criteria were an American Society of Anesthesiology (ASA) physical status of 1 to 3, age 18 to 80 years, and those who met any one of three indications for FOI - cervical instability, predicted difficult airway, a BMI greater than 40 kg m(-2), and who gave written informed consent.Exclusion criteria were emergency awake FOI, mental disability/delirium, polytrauma and contraindication to TLI. INTERVENTIONS: Two anaesthesiologists experienced in both techniques performed all anaesthesia procedures within the study. MAIN OUTCOME MEASURES: The primary outcome was the timing sequence of awake FOI. The incidence of coughing/gagging, ease of tracheal tube placement, mucosal bleeding, cardiopulmonary stability and postoperative outcomes were also investigated. RESULTS: Awake FOI was significantly faster using the TLI technique (mean, 191 s; range, 123 to 447 s; SD, 83.5) than the Enk Fibreoptic Atomizer [mean, 430 s; range, 275 to 773 s; SD, 124.9; (P = 0.0001)]. Patients in group TLI exhibited significantly less gagging (P = 0.047) but more mucosal bleeding (P <  .001). CONCLUSION: Awake FOI using the TLI technique was faster and provided better topical anaesthesia with less gagging during endoscopic intubation. However, the TLI technique was also more invasive. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00948350.

Awake fiberoptic intubation and self-positioning in patients at risk of secondary cervical injury: a pilot study.

BACKGROUND: This study was designed to document the feasibility of self-positioning after awake fiberoptic intubation of the trachea using primarily effective topical anesthesia rather than sedation. METHODS: We investigated 14 patients (ASA physical status 1 to 3) with a neurosurgical diagnosis of cervical instability or at risk of secondary cervical injury, who were scheduled for awake fiberoptic intubation and self-positioning prone. Topical anesthesia was accomplished using an oropharyngeal spray of lidocaine alone or in combination with a transtracheal injection of lidocaine for awake fiberoptic intubation and self-positioning prone. Patients evidencing anxiolysis were given midazolam 2 to 4 mg, i.v.. We assessed the need for sedation, tolerance of the endotracheal tube, patient comfort, incidence of coughing or gagging, and changes in heart rate, blood pressure, and oxygen saturation. In addition, patients were interviewed on the first postoperative day and asked to categorize the experience of awake intubation and positioning as a positive, neutral, or negative experience, or to have no recall. RESULTS: Eleven of the 14 patients turned themselves prone after awake fiberoptic intubation. No additional sedation was necessary for accomplishing positioning. Whereas 50% of the patients (7/14) showed mostly slight coughing or gagging during fiberoptic intubation, none of the patients who were positioned awake had coughing or gagging during tube fixation and prone positioning. The technique was unsuccessful in 3 patients. None of the patients viewed this as a negative experience. CONCLUSIONS: Our study demonstrates that awake fiberoptic intubation and patient self-positioning was feasible in this sample of patients at risk of secondary cervical injury. This technique may extend the opportunity of continuous neurological monitoring in patients with a risk of position-related cervical injury, especially where electrophysiological monitoring is not possible or is unavailable.