Journal of Dental Anesthesia and Pain Medicine

The Korean Dental Society of Anesthsiology (대한치과마취과학회)
권호 표지
DOI QR코드

DOI QR Code

Risk factors affecting the difficulty of fiberoptic nasotracheal intubation

  • Rhee, Seung-Hyun (Department of Dental Anesthesiology, School of Dentistry, Seoul National University) ;
  • Yun, Hye Joo (Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Kim, Jieun (Department of Dental Anesthesiology, School of Dentistry, Seoul National University) ;
  • Karm, Myong-Hwan (Department of Dental Anesthesiology, School of Dentistry, Seoul National University) ;
  • Ryoo, Seung-Hwa (Department of Dental Anesthesiology, School of Dentistry, Seoul National University) ;
  • Kim, Hyun Jeong (Department of Dental Anesthesiology, School of Dentistry, Seoul National University) ;
  • Seo, Kwang-Suk (Department of Dental Anesthesiology, School of Dentistry, Seoul National University)
  • Received : 2020.10.08
  • Accepted : 2020.10.23
  • Published : 2020.10.31
Download PDF
⟨ Previous Next ⟩

Abstract

Background: The success rate of intubation under direct laryngoscopy is greatly influenced by laryngoscopic grade using the Cormack-Lehane classification. However, it is not known whether grade under direct laryngoscopy can also affects the success rate of nasotracheal intubation using a fiberoptic bronchoscpe, so this study investigated the same. In addition, we investigated other factors that influence the success rate of fiberoptic nasotracheal intubation (FNI). Methods: FNI was performed by 18 anesthesiology residents under general anesthesia in patients over 15 years of age who underwent elective oral and maxillofacial operations. In all patients, the Mallampati grade was measured. Laryngeal view grade under direct laryngoscopy, and the degree of secretion and bleeding in the oral cavity was measured and divided into 3 grades. The time required for successful FNI was measured. If the intubation time was > 5 minutes, it was evaluated as a failure and the airway was managed by another method. The failure rate was evaluated using appropriate statistical method. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were also measured. Results: A total of 650 patients were included in the study, and the failure rate of FNI was 4.5%. The patient's sex, age, height, weight, Mallampati, and laryngoscopic view grade did not affect the success rate of FNI (P > 0.05). BMI, the number of FNI performed by residents (P = 0.03), secretion (P < 0.001), and bleeding (P < 0.001) grades influenced the success rate. The AUCs of bleeding and secretion were 0.864 and 0.798, respectively, but the AUC of BMI, the number of FNI performed by residents, Mallampati, and laryngoscopic view grade were 0.527, 0.616, 0.614, and 0.544, respectively. Conclusion: Unlike in intubation under direct laryngoscopy, in the case of FNI, oral secretion and nasal bleeding had a significant effect on FNI difficulty than Mallampati grade or Laryngeal view grade.

Keywords

References

  1. Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003; 58: 249-56. https://doi.org/10.1046/j.1365-2044.2003.03034.x
  2. Rosenstock CV, Thogersen B, Afshari A, Christensen AL, Eriksen C, Gatke MR. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management a randomized clinical trial. Anesthesiology 2012; 116: 1210-6. https://doi.org/10.1097/ALN.0b013e318254d085
  3. Tsukamoto M, Hitosugi T, Yokoyama T. Awake fiberoptic nasotracheal intubation for patients with difficult airway. J Dent Anesth Pain Med 2018; 18: 301-4. https://doi.org/10.17245/jdapm.2018.18.5.301
  4. Ovassapian A, Yelich SJ, Dykes MH, Brunner EE. Fiberoptic nasotracheal intubation--incidence and causes of failure. Anesth Analg 1983; 62: 692-5.
  5. Kim H, So E, Karm MH, Kim HJ, Seo KS. Learning fiberoptic intubation for awake nasotracheal intubation. J Dent Anesth Pain Med 2017; 17: 297-305. https://doi.org/10.17245/jdapm.2017.17.4.297
  6. Smith JE, Jackson AP, Hurdley J, Clifton PJ. Learning curves for fibreoptic nasotracheal intubation when using the endoscopic video camera. Anaesthesia 1997; 52: 101-6. https://doi.org/10.1111/j.1365-2044.1997.23-az023.x
  7. Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance P, et al. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 1997; 87: 1290-7. https://doi.org/10.1097/00000542-199712000-00005
  8. Lundstrom LH, Vester-Andersen M, Moller AM, Charuluxananan S, L'hermite J, Wetterslev J, et al. Poor prognostic value of the modified mallampati score: a meta-analysis involving 177 088 patients. Br J Anaesth 2011; 107: 659-67. https://doi.org/10.1093/bja/aer292
  9. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105-11. https://doi.org/10.1111/j.1365-2044.1984.tb08932.x
  10. Ovassapian A. Fiberoptic tracheal intubation. In: Fiberoptic Airway Endoscopy in Anesthesia and Critical Care. New York: Raven Press; 1990. pp. 57-79.
  11. Hagiwara Y, Watase H, Okamoto H, Goto T, Hasegawa K, Japanese Emergency Medicine Network Investigators. Prospective validation of the modified LEMON criteria to predict difficult intubation in the ED. Am J Emerg Med 2015; 33: 1492-6. https://doi.org/10.1016/j.ajem.2015.06.038
  12. Benumof JL. Both a large and small thyromental distance can predict difficult intubation. Anesth Analg 2003; 97: 1543. https://doi.org/10.1213/01.ANE.0000077668.77618.2F
  13. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429-34. https://doi.org/10.1007/BF03011357
  14. Kandemir T, Savli S, Unver S, Kandemir E. Sensitivity of the combination of mallampati scores with anthropometric measurements and the presence of malignancy to predict difficult intubation. Turk J Anaesthesiol Reanim 2015; 43: 7-12. https://doi.org/10.5152/TJAR.2014.24993
  15. Liu B, Song Y, Liu K, Zhou F, Ji H, Tian Y, et al. Radiological indicators to predict the application of assistant intubation techniques for patients undergoing cervical surgery. BMC Anesthesiol 2020; 20: 238. https://doi.org/10.1186/s12871-020-01153-0
  16. Saghaei M, Safavi MR. Prediction of prolonged laryngoscopy. Anaesthesia 2001; 56: 1198-201.
  17. Delaney KA, Hessler R. Emergency flexible fiberoptic nasotracheal intubation: a report of 60 cases. Ann Emerg Med 1988; 17: 919-26. https://doi.org/10.1016/S0196-0644(88)80672-3
  18. Shigematsu T, Miyazawa N, Kobayashi M, Yorozu T, Toyoda Y, Morisaki H. Nasal intubation with bullard laryngoscope: a useful approach for difficult airways. Anesth Analg 1994; 79: 132-5.
  19. Mahran EA, Hassan ME. Comparative randomised study of $GlideScope^{(R)}$ video laryngoscope versus flexible fibre-optic bronchoscope for awake nasal intubation of oropharyngeal cancer patients with anticipated difficult intubation. Indian J Anaesth 2016; 60: 936-8. https://doi.org/10.4103/0019-5049.195487
  20. Kido H, Komasawa N, Ishio J, Minami T. Use of a modified mcgrath mac and tracheal tube introducer for difficult nasal intubation. J Clin Anesth 2016; 34: 255-6. https://doi.org/10.1016/j.jclinane.2016.04.053
  21. Kim YC, Lee SH, Noh GJ, Cho SY, Yeom JH, Shin WO, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg 2000; 91: 698-701. https://doi.org/10.1213/00000539-200009000-00038
  22. Kim EM, Chung MH, Lee MH, Choi EM, Jun IJ, Yun TH, et al. Is tube thermosoftening helpful for videolaryngoscope-guided nasotracheal intubation?: a randomized controlled trial. Anesth Analg 2019; 129: 812-8. https://doi.org/10.1213/ANE.0000000000003822
  23. Seo KS, Kim JH, Yang SM, Kim HJ, Bahk JH, Yum KW. A new technique to reduce epistaxis and enhance navigability during nasotracheal intubation? Anesth Analg 2007; 105: 1420-4. https://doi.org/10.1213/01.ane.0000281156.64133.bd
  24. Nakayama M, Kataoka N, Usui Y, Inase N, Takayama S, Miura H. Techniques of nasotracheal intubation with the fiberoptic bronchoscope. J Emerg Med 1992; 10: 729-34. https://doi.org/10.1016/0736-4679(92)90533-Y
  25. O'Hanlon J, Harper KW. Epistaxis and nasotracheal intubation-prevention with vasoconstrictor spray. Ir J Med Sci 1994; 163: 58-60. https://doi.org/10.1007/BF02943016
  26. Chi SI, Park S, Joo LA, Shin TJ, Kim HJ, Seo KS. Identifying the more suitable nostril for nasotracheal intubation using radiographs. J Dent Anesth Pain Med 2016; 16: 103-9. https://doi.org/10.17245/jdapm.2016.16.2.103
  27. Sanuki T, Hirokane M, Kotani J. Epistaxis during nasotracheal intubation: A comparison of nostril sides. J Oral Maxillofac Surg 2010; 68: 618-21. https://doi.org/10.1016/j.joms.2009.04.097
  28. Ahmed-Nusrath A, Tong JL, Smith JE. Pathways through the nose for nasal intubation: a comparison of three endotracheal tubes. Br J Anaesth 2008; 100: 269-74. https://doi.org/10.1093/bja/aem350
  29. Thorburn JR, James MF, Feldman C, Moyes DG, Du Toit PS. Comparison of the effects of atropine and glycopyrrolate on pulmonary mechanics in patients undergoing fiberoptic bronchoscopy. Anesth Analg 1986; 65: 1285-9.
  30. Machata AM, Gonano C, Holzer A, Andel D, Spiss CK, Zimpfer M, et al. Awake nasotracheal fiberoptic intubation: patient comfort, intubating conditions, and hemodynamic stability during conscious sedation with remifentanil. Anesth Analg 2003; 97: 904-8.
  31. Roberts JT. Preparing to use the flexible fiber-optic laryngoscope. J Clin Anesth 1991; 3: 64-75. https://doi.org/10.1016/0952-8180(91)90210-E