Comparison of Awake Endotracheal lntu bation in Patients with

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					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
                                                                                         (18-157)                 (4-56)
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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