Comparison of Awake Endotracheal lntu bation in Patients
with Cervical Spine Disease: The Lighted Intubating Stylet
Versus the Fiberoptic Bronchoscope
Ashok K. Saha, MD, Michael Higgins, MD, Garry Walker, MD, Ahmed Badr, MD, and
Lawrence Berman, MD
Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
A wake endotracheal intubation followed by brief
neurological examination before the induction
of general anesthesia is an accepted practice for
patients with cervical spine disease with symptoms of
We designed a study to compare the speed, effective-
ness, and complications
LIS versus the FOB.
of awake endotracheal intu-
bation in patients with cervical spine disease using the
myelopathy and for patients at risk of spinal cord
compression during standard endotracheal intubation
(1). Awake intubation is performed with the fiberoptic Methods
bronchoscope (FOB) either by the nasal or oral route, After approval from our institutional review board, 38
the nasal route being relatively more common. The patients (ASA physical status I-III) with myelopathy
success rate of FOB intubation ranges from 72% to 98% or radiculopathy presenting for cervical stabilization
(2-5). were recruited after their written, informed consent
The lighted intubating stylet (LIS) has been used for was obtained. The patients were randomly assigned to
indirect endotracheal intubation with success rates be- one of two groups: 18 in the FOB group and 20 in the
tween 88% and 100% (6-9). Studies have demon- LIS group.
strated the efficiency of the LIS for managing the Each patient received premeditation with glyco-
difficult airway in children (10) and in patients with pyrrolate 0.2-0.4 mg and midazolam ~0.05 mg/kg IV.
maxillofacial injury (11). Use of the LIS is part of the Identical airway anesthesia was administered with
ASA’s difficult airway algorithm (12). Because the LIS 10% lidocaine spray into the oropharynx, bilateral
glossopharyngeal and superior laryngeal nerve blocks
allows endotracheal intubation with minimal move-
with a total of 6 mL of 1% lidocaine, and transtracheal
ment of the cervical spine, it is ideally suited for
block with 2 mL of 4% lidocaine. Nasotracheal prep-
patients with myelopathy. Fox et al. (13) compared the
aration in the FOB group was performed with 0.25%
LIS with blind nasotracheal intubation in awake pa- phenylephrine spray followed by the passage of nasal
tients with cervical spine disease and found the LIS to airways coated with 2% lidocaine jelly.
be superior, with greater speed, fewer required at- In the FOB group, an endotracheal tube was passed
tempts, and reduced incidence of complications. Be- through a nostril to 15 cm. The FOB (LF-2; Olympus
cause awake nasotracheal intubation with the FOB is a Optical, Tokyo, Japan) was passed through the endo-
common method of endotracheal intubation in pa- tracheal tube, advanced until the larynx was visual-
tients with myelopathy, it is important to compare this ized, and then passed through the vocal cords and
technique with orotracheal intubation using the LIS. trachea until the carina was visualized. The FOB was
fixed and the endotracheal tube was advanced. The
FOB was withdrawn, and endotracheal tube place-
ment was confirmed with capnography. A brief neu-
rologic examination was performed, followed by the
This work was supported by the Department of Anesthesiology,
Vanderbilt University Medical Center, Nashville, TN. induction of general anesthesia.
This material was presented in part at the annual meeting of the In the LIS group, a bite block was placed on the left
American Society of Anesthesiologists, October 1997. side. The LIS (TrachlightTM; Laerdal, Armonk, NY)
Accepted for publication May 5, 1998. was introduced into the endotracheal tube and bent to
Address correspondence and reprints requests to Ashok K. Saha,
MD, Henry Ford Hospital Pain Management Center, 2799 W. Grand a 90” angle. The room lights were dimmed. The endo-
Blvd., WC-228, Detroit, MI 48202. tracheal tube was introduced into the oral cavity and
01998 by the International Anesthesia Research Society
0003.2999/98/$5.00 Anesth Analg 1998;87:477-9 477
478 BRIEF COMMUNICATIONS ASHOK ET AL. ANESTH ANALG
CERVICAL SPINE DISEASE AND INTUBATION TECHNIQUES 1998;87:477-9
advanced until midline illumination was observed in Table 1. Comparison of the FOB and the LIS
the anterior neck. The stylet was withdrawn, and the
FOB (n = 17) LIS (n = 15) P value
endotracheal tube was advanced until the glow disap-
peared behind the sternum. The endotracheal tube Total time (s) 81 t 63 19 t 15 0.0007
holder was then unlocked and the LIS was removed.
Attempts 1.06? 0.08 1.13 2 0.08 0.49
Placement was confirmed, and a brief neurologic ex-
Complications 7 1 0.02
amination was performed.
A maximum of three intubation attempts were al- Values are mean t SD (range).
FOB = fiberoptic bronchoscope, LIS = lighted intubating stylet.
lowed for any technique; then, the alternative method
was attempted. Duration of an attempt was the time
from the introduction of the device into the oral or values did not differ significantly between the two
nasal cavity until its removal. Duration of intubation groups.
was defined as the sum of the duration of all intuba- Mild complications (epistaxis, sore throat) were sig-
tion attempts with the respective technique. Success nificantly more common in the FOB group (M = 7)
was defined as the passing of the endotracheal tube than in the LIS group (n = 1) (Table 1). One patient in
through the vocal cords as verified by capnography. the LIS group developed laryngeal spasm during tra-
Failure of a technique was defined as the inability to cheal extubation, resulting in acute pulmonary edema
intubate after three attempts. All intubations in the LIS in the recovery room, which was managed conserva-
group were performed by a single investigator (AKS), tively without any sequelae. One patient in the FOB
and all intubations in the FOB group were performed group developed mild hemoptysis after extubation,
by one of the other investigators experienced with the possibly secondary to the trauma to the blood vessels
technique. The duration of intubation, number of at- during transtracheal block.
tempts, and immediate complications were recorded
by an independent observer. All patients were evalu-
ated at 24 h for complications.
Demographic data were analyzed by using Stu-
dent’s t-test and Fisher’s exact test as appropriate. Transillumination of the soft tissue of the anterior
Continuous data were analyzed by using analysis of neck with the lighted stylet was described in the liter-
variance (JMP 2.0.4; SAS Institute, Cary, NC). ature as early as 1957 (14,15). There are few studies
regarding the use of the LIS in awake patients; ours is
the first to compare it with the FOB in patients with
cervical spine disease. We found the LIS to be signif-
Results icantly faster than the FOB for performing endotra-
One patient was excluded from the FOB group be- cheal intubation in awake patients with cervical spine
cause a previous nasal fracture would not allow pas- injuries. Although the magnitude of the difference
sage of the endotracheal tube. Two patients were ex- was only 62 s, this could be clinically significant in
cluded from the LIS group for inadequate oral patients with compromised respiratory and/or neuro-
analgesia and three others for protocol violations (sur- logic function.
geon request, desaturation episode, attending anesthe- The LIS was easy to use and effective in awake oral
siologist’s preference). intubations. It may be useful in situations in which the
There was no significant difference between the two FOB is unavailable (e.g., ambulances, emergency de-
groups in age, gender, height, weight, oropharyngeal partments) or in which bronchoscopy is potentially
classification, or amount of preoperative sedation ad- difficult to perform (e.g., airway trauma with secre-
ministered. The duration of the intubation procedure tions). Nevertheless, the rapid speed of intubation we
in the LIS group was significantly shorter than that in found with the TrachlightTM may not apply to other
the FOB group (Table 1). There was no significant LISs, which may not have similarly bright illumina-
difference in the number of attempts required for suc- tion or a retractable stylet. The LIS is relatively inex-
cessful intubation, an there were no failures with the pensive, easy to maintain, and portable, which gives it
primary technique for any patient. Two patients in the additional advantages in these settings. Similarly,
LIS group required a second attempt to achieve suc- these advantages speak well for its use in the operat-
cessful intubation, whereas a single patient in the FOB ing room with the current emphasis on providing
group required a second attempt. Using an intention cost-effective quality care.
to treat analysis including the six cases excluded from
the above analysis, the number of failures for each The authors thank Drs. Letha Mathews and Jane Easdown, and
technique was one (6%) in the FOB group and five anesthesia technicians Joseph Brock and David Moriarty for their
(25%) in the LIS group, which is not statistically sig- assistance.
nificant. Postintubation heart rate and blood pressure
ANESTH ANALG BRIEF COMMUNICATIONS ASHOK ET AL. 479
1998;87:477-9 CERVICAL SPINE DISEASE AND INTUBATION TECHNIQUES
8. Hung OR, Pytka S, Morris I, et al. Clinical trial of a new
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