Why is this important?

This is the first systematic review of RCTs assessing different techniques for conducting awake fibreoptic intubation (AFOI), although the quality of evidence continues to be moderate-low.

Cabrini et al. reviewed 37 RCTs capturing 2,045 AFOI events.

What did they find?

There was no significant success difference among techniques for either local anaesthesia application or procedural sedation, including infusions or boluses of dexmedetomidine, propofol, opioids (fentanyl, sufentanil, remifentanil), ±midazolam, or sevoflurane.

Dexmedetomidine sedation resulted in the fewest desaturation events, and sevoflurane the fewest apnoea events.

Opioids used on their own (ie. without benzodiazepines) resulted in the highest patient recall, particularly remifentanil.

Also of interest...

When conducted by trained experts, AFOI is safe and effective regardless of technique and only very uncommonly results in intubation failure (0.59%) or severe adverse events (0.34%). No permanent morbidity or death was identified.

The take-home message:

When choosing a technique for awake fibre optic intubation, do what you do best – generally this will be what you and your institution are most experienced with.

summary

• Luca Cabrini, M Baiardo Redaelli, Lorenzo Ball, Martina Filippini, Evgeny Fominskiy, Margherita Pintaudi, Alessandro Putzu, Carmine D Votta, Massimiliano Sorbello, Massimo Antonelli, Giovanni Landoni, Paolo Pelosi, and Alberto Zangrillo.
• From the Department of Anaesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy.
• Anesth. Analg. 2019 May 1; 128 (5): 971-980.

AbstractAwake fiberoptic intubation is one of the recommended strategies for surgical patients with anticipated difficult airway, especially when concurrent difficult ventilation is expected. We performed the first systematic review of randomized controlled trials assessing different protocols for awake fiberoptic intubation in anticipated difficult airway, including studies investigating elective awake fiberoptic intubation for scheduled surgery; randomized controlled trials comparing different methods for performing awake fiberoptic intubation; and adult patients with anticipated difficult airway. We excluded studies in the nonoperating theater settings, randomized controlled trials comparing awake fiberoptic intubation with other techniques, and studies based on simulation. Primary outcomes were success rate and death; secondary outcomes were major adverse events. Thirty-seven randomized controlled trials evaluating 2045 patients and 4 areas were identified: premedication, local anesthesia, sedation, and ancillary techniques to facilitate awake fiberoptic intubation. Quality of evidence was moderate-low and based on small-sampled randomized controlled trials. Overall, 12 of 2045 intubation failures (0.59%) and 7 of 2045 severe adverse events (0.34%) occurred, with no permanent consequences or death. All evaluated methods to achieve local anesthesia performed similarly well. No differences were observed in success rate with different sedatives. Dexmedetomidine resulted in fewer desaturation episodes compared to propofol and opioids with or without midazolam (relative risk, 0.51 [95% CI, 0.28-0.95]; P = .03); occurrence of desaturation was similar with remifentanil versus propofol, while incidence of apnoea was lower with sevoflurane versus propofol (relative risk, 0.43 [95% CI, 0.22-0.81]; P = .01). A high degree of efficacy and safety was observed with minimal differences among different protocols; dexmedetomidine might offer a better safety profile compared to other sedatives.

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