Incidence, causes, and management of failed awake fibreoptic intubation—A retrospective study of 833 procedures

Abstract

Awake fibreoptic intubation has been considered a gold standard in the management of the difficult airway. However, failure may cause critical situations. The aim of this study was to investigate the incidence and causes of failed awake fibreoptic intubation at a tertiary care hospital. The study was conducted at St. Olav University Hospital in Trondheim, Norway. Problems occurring during anaesthesia are routinely recorded in the electronic anaesthesia information system (Picis Clinical Solutions Inc.), including difficult intubations. We applied text search on all anaesthesia records between 2011 and 2021 and identified 833 awake fibreoptic intubations. The anaesthesia records were examined to identify failed awake fibreoptic intubations, the cause of failure and how the airway ultimately was secured. Among 233,938 patients who received anaesthesia, 90,397 received tracheal intubation and 833 received awake fibreoptic intubation. Twenty‐nine of the procedures failed. In nine patients the failure caused loss of airway control with desaturation and hypoventilation. The major causes of failure were dislodged tube after induction of general anaesthesia (n = 8), patient distress (n = 5), tube not able to pass (n = 5), and airway bleeding (n = 3). The situations were primarily solved using direct laryngoscopy, with or without bougie, or with video laryngoscopy. Tracheostomy was performed in four patients. Awake fibreoptic intubation failed in 3.5% of patients, most often due to dislocation, problems passing the tracheal tube, or patient discomfort. The failure rate was higher than in previous studies.

Awake tracheal intubation in routine airway management: A retrospective analysis in a tertiary centre

“…The high success rate of ATI.FB at 99,6 % aligns with previously reported success rates [3,5,6]. In a recent Norwegian retrospective study involving 833 ATI:FB (0.92 % of all intubations) 3.5 % resulted in failure [14], attributed to low procedural volume per anesthesiologist and exclusive performance of ATI:FB in difficult airway scenarios. Approximately two-thirds of the failed ATI:FB were salvaged with direct and videolaryngoscopy after induction of anesthesia, while one-third required surgical access.…”

Remimazolam sedation for awake tracheal intubation

“…Currently, the cost of remimazolam is £19 per 20 mg, leading the Scottish Medicines Consortium to recommend against its use for procedural sedation [14]. Maintenance of coughing reflexes with remimazolam may contribute to failure of awake tracheal intubation [15]. Cocaine is routinely used as a topicalising and vasoconstricting agent in our practice.…”